Definition and Facts About Insomnia
- Most adults have experienced insomnia or sleeplessness at one time or another in their lives. However, some of the general population have chronic insomnia.
- Insomnia is not defined by a specific number of hours of sleep that one gets, since individuals vary widely in their sleep needs and practices. Although most of us know what insomnia is and how we feel and perform after one or more sleepless nights, few seek medical advice. Many people remain unaware of the behavioral and medical options available to treat insomnia.
- Insomnia is generally classified based on the duration of the problem. Not everyone agrees on one definition, but generally:
- symptoms lasting less than one week are classified as transient insomnia,
- symptoms between one to three weeks are classified as short-term insomnia, and
- those longer than three weeks are classified as chronic insomnia.
- Insomnia affects all age groups. Among adults, insomnia affects women more often than men. The incidence tends to increase with age.
- Insomnia typically more common in people in lower socioeconomic (income) groups, chronic alcoholics, patients with post-traumatic stress disorder or symptoms, and mental health patients.
- Stress most commonly triggers short-term or acute insomnia.
- Chronic insomnia may develop if it isn't addressed.
- Some surveys have shown that about a third of Americans reported difficulty falling asleep during the previous year and a significant percentage reported problems with long standing insomnia.
- There seems to be an association between depression, anxiety, and insomnia. Although the nature of this association is unknown, people with depression or anxiety were significantly more likely to develop insomnia.
What Is Insomnia?
Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is "difficulty initiating or maintaining sleep, or both" or the perception of poor quality sleep. Insomnia may therefore be due to inadequate quality or quantity of sleep.
What Signs and Symptoms Accompany Insomnia, and How Does Insomnia Affect Health?
Doctors associate a variety of signs and symptoms with insomnia. Often, these symptoms complicate other medical or mental health conditions.
- Some people with insomnia may complain of difficulty falling asleep or waking up frequently during the night. The problem may begin with stress. Then, as you begin to associate the bed with your inability to sleep, the problem may become chronic.
- Most often daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include the following:
- Poor concentration and focus
- Difficulty with memory
- Impaired motor coordination (being uncoordinated)
- Irritability and impaired social interaction
- Motor vehicle accidents because of fatigued, sleep-deprived drivers
- People may worsen these daytime symptoms by their own attempts to treat the symptoms.
- Alcohol and antihistamines may compound the problems with sleep deprivation.
- Others have tried nonprescription sleep aids.
Many people with insomnia do not complain of daytime sleepiness, and in fact, they may have difficulty falling asleep during intentional daytime naps.
What Causes Insomnia?
Insomnia may be caused by a host of different reasons. These causes may be divided into situational factors, medical or psychiatric conditions, or primary sleep problems.
Many of the causes of transient and short-term insomnia are similar and they include:
- Jet lag
- Changes in shift work
- Excessive or unpleasant noise
- Uncomfortable room temperature (too hot or too cold)
- Stressful situations in life (exam preparation, loss of a loved one, unemployment, divorce, or separation)
- Presence of an acute medical or surgical illness or hospitalization
- Withdrawal from drug, alcohol, sedative, or stimulant medications
- Insomnia related to high altitude (mountains)
Uncontrolled physical symptoms (pain, fever, breathing problems, nasal congestion, cough, diarrhea, etc.) can also cause someone to have insomnia. Controlling these symptoms and their underlying causes may lead to resolution of insomnia.
What is insomnia?
What Causes Chronic or Long-Term Insomnia?
The majority of causes of chronic or long-term insomnia are usually linked to an underlying psychiatric or physiologic (medical health) condition.
What Are Mental Health Causes of Insomnia?
The most common mental health problems that may lead to insomnia include:
Insomnia may be an indicator of depression. Many people will have insomnia during the acute phases of a mental illness. As mentioned earlier, depression and anxiety are strongly associated with insomnia and are the most common causes of sleeplessness.
What Are Physical Health Causes of Insomnia?
Physical health causes vary from circadian rhythm disorders (disturbance of the biological clock) and sleep-wake imbalance, to a variety of medical conditions. The following are the most common medical conditions that trigger insomnia:
What Medications Cause Insomnia?
The side effects of certain medications include insomnia, including:
- Certain over-the-counter cold and asthma preparations.
- Prescribed medications for upper respiratory congestion.
- Medications prescribed to treat asthma
- Steroid medications to treat inflammation
- Some medications used to treat high blood pressure.
- Some medications used to treat depression, anxiety, and schizophrenia.
What Are Other Causes of Insomnia?
- Common stimulants associated with poor sleep include caffeine and nicotine. You should consider not only restricting caffeine and nicotine use in the hours immediately before bedtime but also limiting your total daily intake.
- People often use alcohol to help induce sleep, as a nightcap. However, it is a poor choice. Alcohol is associated with sleep disruption and creates a sense of non-refreshed sleep in the morning.
- A disruptive bed partner with loud snoring or periodic leg movements also may impair your ability to get a good night's sleep.
Who Is at Risk for Insomnia?
In addition to people with the above medical conditions, certain groups may be at higher risk for developing insomnia:
- Shift workers with frequent changing of shifts
- Adolescents or young adult students
- Pregnant women
- Women in menopause
- People who abuse drugs
What Are Primary Sleep Disorders?
In addition to the causes and conditions listed above, there are also a number of conditions that are associated with insomnia in the absence of another underlying condition. These are called primary sleep disorders, in which the sleep disorder is the main cause of insomnia. These conditions generally cause chronic or long-term insomnia. Some of the diseases are listed below:
- Idiopathic insomnia (unknown cause) or childhood insomnia, which start early on in life and results in lifelong sleep problems. This may run in families.
- Central sleep apnea. This is a complex disorder. It can be the primary cause of the insomnia itself or it may be caused by other conditions, such as brain injury, heart failure, high altitude, and low oxygen levels.
- Restless legs syndrome (a condition associated with creeping sensations in the leg during sleep that are relieved by leg movement)
- Periodic Limb movement disorder (a condition associated with involuntary repeated leg movement during sleep)
- Circadian rhythm disorders (disturbance of the biological clock) which are conditions with unusual timing of sleep (for example, going to sleep later and waking up late, or going to sleep very early and getting up very early).
- Sleep state misperception, in which the patient has a perception or feeling of not sleeping adequately, but there are no objective (polysomnographic or actigraphic) findings of any sleep disturbance.
- Insufficient sleep syndrome, in which the person's sleep is insufficient because of environmental situations and lifestyle choices, such as sleeping in a bright or noisy room.
- Inadequate sleep hygiene, in which the individual has poor sleep or sleep preparation habits (described in the following treatment section.)
When to Seek Medical Care for Insomnia
When to call the doctor
- A person with insomnia needs a doctor's attention if it lasts longer than three to four weeks, or sooner if it interferes with a person's daytime activities and ability to function.
When to go to the hospital
- Generally, a person will not be hospitalized for most types of insomnia. However, when a lack of sleep results in an accident or other bodily harm, the patient might be admitted to the hospital for treatment of a condition resulting from the insomnia.
- Worsening pain or increased difficulty breathing at night also may indicate a person needs to seek emergency medical care. However, chronic insomnia, if not associated with an injury or resultant life-threatening problem typically does not belong in the emergency department. It is a condition to discuss with a primary care physician or a psychiatrist.
How Insomnia Is Diagnosed?
The health-care professional will begin an evaluation of insomnia with a complete medical history. As with all medical evaluations, a complete medical history and physical examination are important aspects of assessment and treatment of insomnia.
The health-care professional will seek to identify any medical or psychological illness that may be contributing to the patient's insomnia. A thorough medical history and examination including screening for psychiatric disorders and drug and alcohol use is paramount in evaluation of a patient with sleep problems. Physical examination may particularly focus on heart and lung examination, and measurement of size of the neck and visualizing oral and nasal air passages (to see whether sleep apnea needs to be assessed in more detail).
- A patient with insomnia may be asked about chronic snoring and recent weight gain. This may direct an investigation into the possibility of obstructive sleep apnea. In such an instance, the doctor may request an overnight sleep test (polysomnogram). Sleep studies are frequently done in specialized "sleep labs" by doctors trained in sleep medicine, frequently working with pulmonary (lung) specialists. This test is not part of the routine initial workup for insomnia, however.
- Sleep history can be helpful in evaluating a patient with insomnia. Sleep schedule, bedroom and sleep habits, timing and quality of sleep, daytime symptoms, and duration of insomnia can provide useful clues in the assessment of a patient with insomnia. Preparation for a visit with your primary care physician to discuss your sleep problems should include a diary or journal of your sleep or lack thereof. When do you go to bed? How long does it take for you to fall asleep? Do you wake after a few hours? Does this happen every night? Is it associated with any particular activity? What did you do before going to bed on the nights you cannot sleep? How many nights a week do you have trouble sleeping? Keeping a journal for even just two weeks before seeing your doctor will help both of you gain insight into the problem. (See the paragraph below for more information on sleep diaries.)
- Routine medications, alcohol use, drug use, stressful social and occupational situations, sleeping habits or snoring of the bed partner, and work schedule are some of the other topics that may be discussed by your doctor when evaluating insomnia.
- The Epworth Sleepiness Scale is a validated questionnaire that can be used to assess daytime sleepiness. This scale may be helpful in assessing insomnia.
- Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and on-board memory and can provide objective data on daytime activity.
- A sleep diary can be filled out daily for a period of 2 weeks. The patient is asked to write down times when they go to bed, fall asleep, awake from sleep, stay awake in bed, and get up in the morning. They can record amount of daily exercise, alcohol and caffeine intake, and medication. The diary will include the patient's personal assessment of their alertness at various times of the day on two consecutive days within the 2 week period.
How Insomnia Can Be Treated?
In general, transient insomnia resolves when the underlying trigger is removed or corrected. Most people seek medical attention when their insomnia becomes chronic.
The main focus of treatment for insomnia should be directed towards finding the cause. Once a cause is identified, it is important to manage and control the underlying problem, as this alone may eliminate the insomnia all together. Treating the symptoms of insomnia without addressing the main cause is rarely successful. In the majority of cases, chronic insomnia can be cured if its medical or psychiatric causes are evaluated and treated properly.
The following therapies may be used in conjunction with therapies directed towards the underlying medical or psychiatric cause. They are also the recommended therapies for some of the primary insomnia disorders.
Generally, treatment of insomnia entails both non-pharmacologic (non-medical) and pharmacologic (medical) aspects. It is best to tailor treatment for an individual patient based on the potential cause. Studies have shown that combining medical and non-medical treatments typically is more successful in treating insomnia than either one alone.
What OTC or Prescription Medications Treat and Cure Insomnia?
There are numerous prescription medications to treat insomnia. Generally, it is advised that they should not be used as the only therapy and that treatment is more successful if combined with non-medical therapies. In a study, it was noted that when sedatives were combined with behavioral therapy, more patients were likely to wean off the sedatives than if sedatives were used alone. The most commonly used sleeping pills are listed in the following sections including over-the-counter medications and natural sleep aids.
Prescription Sleep Aids
- Benzodiazepine sedatives: Six of these sedative drugs have been used to treat insomnia. There are reports of subjective improvement of quality and quantity of sleep when using these medications. Examples include temazepam (Restoril), flurazepam (Dalmane), triazolam (Halcion), estazolam (ProSom, Eurodin), lorazepam (Ativan), and clonazepam (Klonopin).
- Nonbenzodiazepine sedatives: Examples include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien or Intermezzo).
- Orexin antagonists: Suvorexant (Belsomra), is newer class of medication that works by decreasing activity in the wake center of the brain and therefore promoting sleep.
- Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the US Food and Drug Administration (FDA) for treatment of insomnia characterized by difficulty falling asleep.
- Some antidepressants (for example, amitriptyline [Elavil, Endep] and trazodone [Desyrel]) have been used for the treatment of insomnia in patients with co-existing depression because of some sedative properties.
Over-the-counter (OTC) medications
- Antihistamines with sedative properties [for example, diphenhydramine (Benadryl) or doxylamine] have also been used in treating insomnia as they may induce drowsiness, but they do not improve sleep and should not be used to treat chronic insomnia.
- Melatonin: Melatonin is secreted by the pineal gland, a pea-sized structure at the center of the brain. Melatonin is produced during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. At night, melatonin is produced to help your body regulate your sleep-wake cycles. The amount of melatonin produced by your body seems to decrease as you get older. Melatonin supplements may be beneficial in older patients who have difficulty staying asleep.
Sleep Disorders: Foods That Help Sleep or Keep You Awake
What Natural Treatments or Home Remedies Help Cure Insomnia?
Herbal remedies for insomnia
- Valeriana officinalis (Valerian) is a popular herbal medication used in the United States for treating insomnia with possibly some benefit in some patients with chronic insomnia.
- St. Johns Wort and chamomile have not shown any real benefit in treating insomnia.
- Other natural herbal sleeping aids such as, dogwood, kava kava, and L-tryptophan, may be associated with potential adverse effect when used for insomnia.
Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple steps can be taken to improve a patient's sleep quality and quantity. These steps include:
- Sleep as much as you need to feel rested; do not oversleep.
- Exercise regularly at least 20 minutes daily, ideally 4-5 hours before your bedtime.
- Avoid forcing yourself to sleep.
- Keep a regular sleep and awakening schedule, i.e. go to bed and get up at the same time every day.
- Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.) Avoid "night caps," (alcoholic drinks prior to going to bed).
- Do not smoke, especially in the evening.
- Do not go to bed hungry.
- Adjust the environment in the room (lights, temperature, noise, etc.)
- Do not go to bed with your worries; try to resolve them before going to bed.
Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed.
Stimulus control therapy also consists of a few simple steps that may help patients with chronic insomnia.
- Go to bed when you feel sleepy.
- Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep and sexual activity.
- If you do not fall asleep 30 minutes after going to bed, get up and go to another room and resume your relaxation techniques.
- Set your alarm clock to get up at a certain time each morning, even on weekends. Do not oversleep.
- Avoid taking long naps in the daytime.
Restricting your time in bed only to sleep may improve your quality of sleep. This therapy is called sleep restriction. It is achieved by averaging the time in bed that the patient spends only sleeping. Rigid bedtime and rise time are set, and the patient is forced to get up at the rising time even if they feel sleepy. This may help the patient sleep better the next night because of the sleep deprivation from the previous night. Sleep restriction has been helpful in some cases.
Other simple measures that can be helpful to treat insomnia include:
- Avoid large meals and excessive fluids before bedtime
- Control your environment.
- Light, noise, and undesirable room temperature can disrupt sleep. Shift workers and night workers especially must address these factors. Dimming the lights in the bedroom, relaxation, limiting the noise, and avoiding stressful tasks before going to bed may be beneficial. (Refer to sleep hygiene and relaxation therapy above.)
- Avoid doing work in the bedroom that should be done somewhere else. For example, do not work or operate your business out of your bedroom and avoid watching TV, reading books, and eating in your bed.
A person's circadian rhythm (biological clock) is particularly sensitive to light. Parents who need to sleep during the day may have to make child care arrangements to allow them to sleep.
What Other Therapies or Lifestyle Changes Can Help Insomnia?
Insomnia from shift changes
- Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep deprivation in shift workers.
- A person should shift their schedules forward in a clockwise direction, from days to evening, then evenings to night shift, and allow sufficient time to adapt (at least one week) between shift changes.
- Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as a rhythm synchronizer.
- Shift workers should stress the importance of good sleep habits with regular bedtime and awakening.
- Supplemental naps may be necessary to ensure work time alertness.
- Discuss the use of naps with a doctor.
- Some people promote using short-acting sedatives in the first few days following a shift change, but not everyone agrees.
Insomnia from acute stresses
- Stress may be positive or negative, and concerns about sleep may vary. Many stressors will go away with support and reassurance.
- Education about the importance of good sleep habits is also helpful.
- Some people may need short-term treatment with medications. A doctor will often work toward the lowest effective dose with a short-acting sedative to achieve proper sleep.
How Can I Prevent Insomnia?
General recommendations for prevention of insomnia include the following:
- Work to improve your sleep habits.
- Learn to relax. Self-hypnosis, biofeedback and relaxation breathing are often helpful.
- Control your environment. Avoid light, noise, and excessive temperatures. Use the bed only to sleep and avoid using it for reading and watching TV. Sexual activity is an exception.
- Establish a bedtime routine. Have a fixed wake time.
- Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and reduce the use of stimulants including caffeine and nicotine.
- If you do not fall asleep within 20 to 30 minutes, try a relaxing activity such as listening to soothing music or reading.
- Limit daytime naps to less than 15 minutes unless directed by your doctor.
- It is generally preferable to avoid naps whenever possible to help consolidate your night's sleep.
- There are certain sleep disorders, however, that will benefit from naps. Discuss this issue with your doctor.
How Long Insomnia Last?
Recovery from insomnia can vary.
- If you have insomnia caused by jet lag, your symptoms will generally clear up within a few days.
- If you are depressed and have had insomnia for many months, it is unlikely that your symptoms will go away on their own. You may need further evaluation and treatment.
- Your outcome will also depend on coexisting medical conditions, which may include congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic pain syndromes.
REFERENCES: eMedicine.com. Insomnia.
FDA.gov. Medication Guide Intermezzo. <http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/022328s000mg.pdf>