Insomnia

Insomnia is the feeling of inadequate or poor sleep because of one or more of the following: trouble falling asleep; trouble remaining asleep; awakening too early; or non-restorative sleep. For insomnia to be diagnosed, these symptoms must be present at least three nights per week and the sleep difficulty is present for at least one month. All of these symptoms can lead to daytime drowsiness, poor concentration, irritability, and the inability to feel refreshed and rested upon awakening. Some 50 to 70 million Americans have a sleep or wakefulness disorder, according to the Centers for Disease Control and Prevention.

Insomnia is not defined by the hours of sleep a person gets or how long it takes to fall asleep. Individuals vary in their need for and satisfaction with sleep. A feature of insomnia is that individuals experience distress or impairment in functioning as a result of their poor sleep.

Insomnia can be classified as episodic, persistent, or recurrent. Insomnia lasting from one month to three months is episodic. If the symptoms last three months or longer, the insomnia is said to be persistent. Insomnia is considered to be recurrent if two or more episodes occur within the space of one year.

The development and course of insomnia as cataloged by the DSM-5 include:
The onset of insomnia symptoms can occur at any time during life, but the first episode is more common during young adulthood. Less frequently, insomnia begins in childhood or ad­olescence. In women, new-onset insomnia may occur during menopause and persist even after other symptoms, such as hot flashes, have resolved. Insomnia may have a late-life onset, which is often associated with the onset of other health-related conditions.

Insomnia can be situational, persistent, or recurrent. Situational or acute insomnia usu­ally lasts a few days or a few weeks and is often associated with life events or rapid changes in sleep schedules or environment. It usually resolves once the initial event subsides. For some individuals, perhaps those more vulnerable to sleep disturbances, in­somnia may persist long after the initial event, possibly because of conditioning factors and heightened arousal. The factors that precipitate insomnia may differ from those that perpetuate it. 

For example, an individual who is bedridden with a painful injury and has difficulty sleeping may then develop negative associations with sleep. Conditioned arousal may then persist and lead to persistent insomnia. A similar course may develop in the context of acute psychological stress or a mental disorder. For instance, insomnia that occurs during an episode of major depressive disorder can become a focus of attention, with consequent negative conditioning, and persist even after resolution of the depressive episode. In some cases, insomnia may also have an insidious onset without any identifi­able triggering factor.

The course of insomnia may also be episodic, with recurrent episodes of sleep difficul­ties associated with the occurrence of stressful events. Chronicity rates range from 45 percent to 75 percent for follow-ups of one to seven years. Even when the course of insomnia has become chronic, there is night-to-night variability in sleep patterns, with an occasional restful night's sleep interspersed with several nights of poor sleep. The characteristics of insomnia may also change over time. Many people with insomnia have a history of "light" or easily disturbed sleep prior to the onset of more persistent sleep problems.

Insomnia complaints are more prevalent among older adults. The type of symptom changes because of age, with difficulties initiating sleep being more common among young adults and problems maintaining sleep occurring more fre­quently among middle-aged and older individuals.

Difficulties initiating and maintaining sleep can also occur in children and adolescents, but there are more limited data on prevalence, risk factors, and comorbidity during these developmental phases. Sleep difficulties in childhood can result from con­ditioning factors (a child who does not learn to fall asleep or return to sleep without the presence of a parent, for example) or from the absence of consistent sleep schedules and bedtime routines. Insomnia in adolescence is often triggered or exacerbated by irregular sleep sched­ules. In both children and adolescents, psychological and medical fac­tors can contribute to insomnia.

Symptoms

The diagnostic criteria of insomnia include difficulty falling asleep, difficulty maintaining sleep, and early-morning awakening with an inability to fall back to sleep. Sleep disturbances such as these cause significant distress and impairment in a multitude of areas in functioning, including social, academic, behavioral, and work.

Signs and symptoms as cataloged by the DSM-5:

A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:

  • Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
  • Difficulty maintaining sleep, characterized by frequent awakenings or problems re­turning to sleep after awakenings. (In children, this may manifest as difficulty return­ ing to sleep without caregiver intervention.)
  • Early-morning awakening with the inability to return to sleep.

The sleep disturbance causes clinically significant distress or impairment in social, oc­cupational, educational, academic, behavioral, or other important areas of functioning.

  • Sleep difficulty occurs at least 3 nights per week.
  • Sleep difficulty is present for at least 3 months.
  • Sleep difficulty occurs despite adequate opportunity for sleep.
  • The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (narcolepsy, a breathing-related sleep dis­order, a circadian rhythm sleep-wake disorder, a parasomnia).
  • The insomnia is not attributable to the physiological effects of a substance (an illicit drug, a medication).

Co-existing mental disorders and medical conditions do not adequately explain the pre­dominant complaint of insomnia.

Causes

Certain conditions seem to make individuals more likely to experience insomnia. Examples of these conditions include:

  • Advanced age (insomnia occurs more frequently in older adults)
  • Occurs more frequently among females
  • Having a history of depression

There are a number of possible causes of insomnia:

  • Shift work
  • Jet lag or other sleep-wake disturbances
  • Depression
  • Anxiety
  • Excessive worry
  • Stress
  • Grief
  • Intense excitement
  • Poor sleep conditions, such as a bed or bedroom not conducive to sleep
  • Use of nicotine, caffeine, alcohol, or stimulants
  • Eating before bedtime
  • Medications or illicit drugs
  • Medication withdrawal
  • A new medication
  • A change in medication
  • Bright-light exposure
  • Excessive daytime sleep
  • Excessive stimulation at bedtime, physical or intellectual
  • Overactive thyroid
  • Conditions that impair breathing
  • Arthritis or other chronic illness
  • Heartburn or other gastrointestinal condition
  • Co-occurring disorders or medical illness
  • Stroke
  • Restless leg syndrome
  • Aging
  • Menopause 

Episodic or situational insomnia generally occurs in people who are temporarily experiencing one or more of the following. These can often be resolved on their own.

  • Stress
  • Environmental disturbances, such as noise
  • Change in environment
  • Extreme temperatures
  • Jet lag or other sleep-wake disturbances
  • Medication side effects

The more complex chronic insomnia often results from factors, including underlying physical or mental disorders. Depression, for one, is a common cause of chronic insomnia. Other underlying causes include asthma, sleep apnea, narcolepsy, restless legs syndrome, arthritis, kidney disease, heart failure, Parkinson's disease, and hyperthyroidism. Chronic insomnia may also be due to behavior problems, including the abuse of caffeine, alcohol, other substances, stress, shift work, or other lifestyle behaviors.

Some behaviors can exacerbate insomnia, or they may cause the sleep difficulty in the first place:

  • Worrying about difficult sleep
  • Excessive caffeine
  • Alcohol intake before bedtime
  • Smoking cigarettes before bedtime
  • Excessive afternoon or evening naps
  • Sleep-wake disruptions

Treatment

Situational or episodic insomnia, from jet lag for example, normally does not require treatment as episodes last only a few days or weeks. In these instances, the individual’s sleep cycle may return to normal without treatment. 

In other cases of episodic insomnia, daytime sleepiness and impaired performance can be remedied with short-acting sleeping pills. However, extended use of these medications is not advised. They also come with side effects such as daytime haziness and impaired function. Over-the-counter medication is not recommended for insomnia. These non-prescription sleep aids contain antihistamines, which also can cause side effects of daytime sleepiness, dizziness, confusion, among other side effects. 

There are behavioral techniques that can alleviate insomnia, including relaxation therapy, sleep restriction, reconditioning and psychotherapy

Relaxation Therapy: This techniques can reduce or relieve anxiety and body tension. Relaxation through breathing exercises or biofeedback can help the individual's racing mind; relaxing the muscles may lead to restful sleep. However, it may take practice.

Sleep Restriction: Decreasing the time one spends in bed as well as avoiding the daytime nap are helpful strategies. Doing so may increase the feeling of being tired, therefore increasing the hours one actually sleeps. A sleep restriction program allows only a few hours of sleep at night, gradually increasing the time until normal sleep returns.

Reconditioning or Stimulus Control: Reconditioning the individual into associating the bed with sleep can be a useful technique. In this case, the bed is used for sleep and sex and no other activities. The recommendations for this include:

  • Go to bed only when sleepy
  • If the individual is unable to sleep, he or she should get up
  • Stay up until sleepy
  • Avoid napping
  • Stick to a schedule; wake up and go to bed at the same time daily

Light Therapy: Using light therapy, with a light box, to help reset the internal clock is also a useful technique. 

Cognitive Behavioral Therapy: Talking to a therapist or attending group therapy sessions can help reduce sleep anxiety. It focuses on thoughts and behaviors that disrupt sleep. CBT also promotes good sleep hygiene. It also uses positive thought to connect bed with sleep. Often, people who suffer poor sleep link negative thoughts and anxious feelings with sleep. In many cases, they are anxious about sleep itself. CBT addresses the racing mind, with the goal of settling down thoughts and inner dialog. CBT also adheres to the above techniques: keeping a sleep schedule, saving the bed for sleep, for example. CBT-I is a form of CBT developed specifically to treat insomnia.

The individual may need to see the therapist weekly over two to three months. For chronic insomnia sufferers, this therapy works alongside prescription medication. People who suffer insomnia with major depressive disorder, a combination of antidepressant medication and CBT proves effective.

Tips for a Good Night's Sleep:

Set a schedule:

  • Go to bed at a set time each night and get up at the same time each morning.
  • Physical activity: Get regular exercise of 20 to 30 minutes daily
  • Avoid nicotine
  • Limit caffeine and alcohol, especially in the evening hours
  • Avoid heavy meals before bedtime
  • Relax before bed
  • Set a bedtime routine, such as a warm bath, reading or another relaxing routine
  • Sleep until sunlight
  • Don't lie in bed awake
  • If unable to sleep, get up and read or listen to music until sleepy

Control your bedroom environment:

  • Avoid bright lights before bedtime
  • Use comfortable bedding
  • Limit noises and distractions: TV, computer, or a pet. 
  • Keep the bed for sleep and sex
  • Set a cool and comfortable temperature

See a primary care physician if sleeping difficulties continue. A sleep specialist may be recommended. Most sleep disorders can be treated effectively.

References

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Heart, Lung, and Blood Institute Information Center
  • National Institute of Neurological Disorders and Stroke
  • National Institutes of Health - National Library of Medicine

Last reviewed 02/07/2019