Insomnia

Insomnia is a sleep disorder associated with problems with sleep quality or quantity ^[1]. It can be treated with sleep hygiene training, therapy, and medications ^[2].

What is insomnia?

Insomnia is classified as a sleep disorder that interferes with the ability to acquire sufficient sleep or enjoy high-quality sleep. People who struggle with insomnia may have a difficult time falling asleep at night, which cuts into their total sleep time ^[1].

Alternatively, insomnia may involve awakening early in the morning, before a reasonable time, and being unable to fall back asleep. Finally, some people with insomnia frequently awaken at night or have difficulty returning to sleep after nighttime awakenings ^[1].

Types of insomnia

All forms of insomnia involve difficulty with sleep quality or quantity, but there are various types of insomnia based on the duration of symptoms ^[1]. These types of insomnia are detailed below: 

• Episodic Insomnia:Episodic insomnia occurs for at least one month but less than three months. For instance, a person may have a brief bout of sleep disturbances during a stressful time at work.
• Persistent (chronic) Insomnia:In the case of persistent insomnia, symptoms last a minimum of three months but can persist for much longer. With persistent insomnia, a person may experience ongoing fatigue from chronic sleep difficulties.
• Recurrent Insomnia: This form of insomnia involves two or more episodes of sleep disturbances over a year. A person may have trouble sleeping for a few months, return to sleeping normally, and then have another bout of insomnia a few months later.
• Other forms of insomnia: Insomnia can also be labeled as occurring with another sleep disorder, such as sleep apnea. In addition, it can occur alongside another non-sleep mental disorder, like a substance use disorder. Finally, it can occur with other medical comorbidities, such as heart disease.

Symptoms of insomnia

Insomnia symptoms can vary from person to person, but in general, people with insomnia show some or many of the following symptoms ^[3]:

• Lying awake for a significant amount of time before falling asleep at night
• Sleeping in short bursts and then waking up and being unable to fall back asleep
• Spending most of the night awake or tossing and turning
• Waking up very earlyand then being unable to fall back asleep before it’s time to start the day
• Feeling as if you’ve not slept at all when you wake up in the morning
• Lacking energy during the day
• Experiencing sleepiness during the day
• Taking naps most days to compensate for lack of sleep at night

Causes of insomnia

There is no single, precise cause of insomnia. Instead, several potential risk factors increase the likelihood of a person developing insomnia. When looking at the causes of insomnia, it’s important to understand that there are two types: primary and secondary. Sleep disturbance is not the result of another medical condition in primary insomnia. In secondary insomnia, sleep disturbance is the result of the adverse effects of a medical or psychiatric problem or because of the misuse of substances ^[4].

The causes of insomnia are discussed in more detail below, broken down between primary and secondary insomnia.

Causes of primary insomnia

Some risk factors for primary insomnia include ^[3]:

• Stress
• Emotional problems resulting from divorce or other life stressors
• Low socioeconomic status
• Working the night shift or having frequent changes in your work schedule
• Traveling through different time zones
• Lack of exercise
• Being African American

Some of the factors above, such as working the night shift, can be direct causes of insomnia. In contrast, other factors, like being African American, simply increase the risk that a person will experience insomnia.

Causes of secondary insomnia

Numerous mental health disorders, medications, and medical conditions increase the risk of insomnia. While the list below is not exhaustive, it includes various medical and mental health factors that can contribute to insomnia ^[5]:

• Depression
• Generalized anxiety disorder
• Panic disorder
• Schizophrenia
• Post-traumatic stress disorder
• Bipolar disorder
• Obsessive-compulsive disorder
• Borderline personality disorder
• Heart disease
• Respiratory diseases
• Gastrointestinal problems (ulcers, acid reflux)
• Headaches
• Stroke
• Neurological disorders
• Traumatic brain injury
• Arthritis
• Brain tumors
• Fibromyalgia
• Sleep disorders (sleep apnea)
• Cancer
• Chronic pain
• Restless leg syndrome
• Use of certain medications (albuterol, stimulant drugs, antidepressants, and certain blood pressure medications)

Diagnosing insomnia

A doctor or other healthcare professional diagnosing insomnia will gather a complete psychiatric and medical history to determine if a diagnosis of insomnia is warranted and to help clarify the causes and nature of a person’s sleep disturbance. They will likely begin by asking about the history of sleep disturbance, including when it began and how it looks. For example, they will ask if a person frequently wakes at night, has trouble falling asleep at the start of the night, or struggles to fall back asleep after waking in the early morning hours ^[2].

Specific diagnostic tools may be utilized to make an insomnia diagnosis. For example, a doctor may administer a standardized questionnaire that assesses your quality of sleep and perform blood work to test thyroid, blood sugar, iron, and organ functioning. In addition, a patient undergoing evaluation for insomnia may also complete a test called polysomnography to test for co-occurring sleep disorders like sleep apnea ^[2].

Finally, a doctor may ask a patient to wear a wrist actigraph. This device measures total sleep time, how long it takes to fall asleep at night, how frequently they awaken after falling asleep, and whether they nap during the day ^[2] 

A diagnosis is made if a patient meets the diagnostic criteria for insomnia. In addition, if co-occurring conditions like depression contribute to sleep disturbance, a patient may also be diagnosed with a co-occurring disorder.

The diagnostic criteria for insomnia include ^[1]: 

• A complaint of poor sleep quality or quantity
• Trouble falling asleep and/or staying asleep, or waking early in the morning and being unable to return to sleep
• High distress or being unable to function in important life areas, such as at work or school, because of sleep disturbance
• Experiencing sleep problems at least three nights a week
• Suffering from a lack of sleep despite having enough time to get adequate sleep
• Sleep disturbance doesn’t occur solely because of another sleep disorder, medical problem, or mental health condition.

Prevention of insomnia

You can reduce your risk of developing insomnia by establishing healthy sleep habits. Healthy sleep hygiene includes limiting caffeine and alcohol consumption before bedtime, following a regular exercise routine, developing healthy eating habits, and limiting naps during the day. It’s also important to set a regular sleep schedule, with the same bedtime and wake-up time each day ^[2].

Treatment for insomnia

Insomnia is treated primarily through therapy and medication, but it may also be treated with a specific technique called sleep restriction. Each of these modalities is described further below.

Therapy

Cognitive behavioral therapy (CBT) is one of the primary counseling techniques used to treat insomnia. It is effective for increasing total sleep time, reducing the time it takes for a person to fall asleep, and decreasing nighttime awakenings. It has also been found to be more effective than medication forinsomnia. CBT for insomnia can be delivered in individual or group format or via teletherapy. This modality helps people to change dysfunctional sleep-related thoughts and behaviors, such as anxiety surrounding sleep, and it incorporates strategies like relaxation training and education on healthy sleep ^[2].

Another therapeutic modality, which is sometimes paired with CBT and other times delivered on its own, is stimulus control therapy. This method teaches people with insomnia to correct behaviors leading to poor sleep. For instance, people are trained to stop eating, reading, or using digital devices in bed, because this leads to the body associating the bed with activities aside from sleep ^[2].

Medication

Several medications are used to treat insomnia, including those listed below:

• Benzodiazepines, like Halcion
• Zolpidem
• Zaleplon
• Eszopiclone
• Melatonin (available over-the-counter)
• Ramelteon
• Tasimelteon
• Suvorexant
• Doxepin
• Antidepressant drugs,including trazodone
• Atypical antipsychotics like quetiapine
• Anticonvulsant drugs like gabapentin

Sleep Restriction

In sleep restriction therapy, a person limits or restricts the number of hours in bed. The hope is that sleep restriction will increase the drive for sleep and reduce nighttime awakenings. A person is likely to experience some daytime sleepiness with this method, and as sleep improves, sleep time can be increased ^[2].

Self-care for insomnia

If you live with insomnia, there are steps you can take to care for yourself and reduce the impact of your symptoms. Some self-care strategies include:

• Maintaining a cool, quiet bedroom.
• Engaging in relaxing activities such as stretching or quiet reading before bed.
• Limiting the use of electronic devices in the hour before bed.
• Making time for physical activity during the day to increase your drive for sleep.
• Limiting the use of caffeine.
• Learning relaxation techniques, such as yoga, deep breathing, or progressive muscle relaxation.

Frequently asked questions about insomnia

If you’re looking for information on the treatment of insomnia, the answers to the following questions are also helpful.

Are there any complications of insomnia?

Left untreated, insomnia can lead to poor quality of life ^[2]. Insomnia is also linked to daytime sleepiness and lack of energy, making it difficult to stay on task, pay attention, learn, and remember important information. In severe cases, insomnia can lead to problems like motor vehicle crashes. It can also make a person depressed, irritable, or anxious ^[3].

Furthermore, insomnia can reduce productivity at work and increase the risk of several health problems, including heart disease, diabetes, obesity, high blood pressure, and asthma ^[2].

How common is insomnia?

Prevalence data show that 10 to 15% of the population experiences insomnia.