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Insomnia

Overview
Insomnia is a sleep disorder that is characterized by sleeplessness, inadequate sleep, or poor quality sleep. 

The amount of sleep needed varies from person to person. In general, however, most people function best with seven or eight hours of sleep.

Insomnia can be a serious health and wellness concern because lack of sleep, especially good quality sleep, can affect your ability to function at work, in other daily activities, and in personal relationships.
Insomnia in Depth

Some people experience short-term insomnia, while others are affected for longer periods. Short-term insomnia that lasts for a few days or weeks is considered acuteinsomnia and is generally associated with a traumatic or stressful event. Chronicinsomnia, on the other hand, is longer-term issue, with sleep disturbances occurring at least three nights a week for a month or longer. Insomnia can also vary in severity—some cases are mild, whereas others are severe.

Some people develop habits as a result of insomnia or in response to drowsiness; these habits may worsen sleeplessness. They include taking naps, worrying about sleep, and going to bed early.

Who experiences insomnia?

Both men and women can experience insomnia, but it tends to affect more women than men. Possible explanations for the higher frequency among women include hormonal changes associated with the menstrual cycle and menopause; hormonal, physical, and emotional changes experienced during pregnancy; and a higher prevalence among women of medical conditions that can cause secondary insomnia (including depression, anxiety, and sleep disorders).

Risk factors for insomnia include: stress, depression, and emotional distress (such as divorce or death of a loved one), night work, travel with time changes, and an inactive lifestyle.

Types of Insomnia

Insomnia is divided into two types: primary insomnia and secondary insomnia.

Primary Insomnia

Primary insomnia is not a symptom or side effect of another medical condition but occurs independently of other illnesses, meaning that it is a condition of its own. Primary insomnia may affect an individual throughout life or may be triggered by stressful events, an unconventional work schedule (such as night work), travel, or other disruptive circumstances.

Secondary Insomnia

Unlike primary insomnia, secondary insomnia is a symptom or side effect of another health condition. Underlying medical causes of secondary insomnia include depression or anxiety, chronic pain, overactive thyroid, gastrointestinal problems, other sleep disorders (such as sleep apnea or restless leg syndrome), stroke, Alzheimer’s disease, or menopause.

Environment and lifestyle factors may also cause secondary insomnia. Examples of these factors include: certain medications (such as asthma, heart, allergy, and cold medicines); use of caffeine, tobacco, and alcohol; and poor sleep environment (a bedroom that’s too noisy or not dark enough, for example).

Secondary insomnia may go away once the issue causing sleeplessness is treated. In some cases, however, further treatment of insomnia itself is required

Symptoms

Symptoms of insomnia include the following:

  • Lying awake for long periods with difficulty falling asleep
  • Waking up during the night and having trouble getting back to sleep
  • Waking up too early in the morning
  • Feeling like you haven’t slept at all

If you’re not sleeping well or enough, you may feel sleepy, have low energy, have trouble thinking clearly and staying focused, and feel irritable or depressed.

Diagnosis

Your doctor can help you determine if you are experiencing insomnia. If you feel that you are having trouble sleeping, such as falling asleep or staying asleep, and that lack of sleep is affecting your daily activities, you may want to consult your doctor.

A sleep diary may help you and your doctor understand and treat insomnia. This diary should include a daily record of what time you fall asleep and wake up, any changes in your sleep and bedtime routines, and how you feel during the day. Also be prepared to tell your doctor about factors that may be affecting the quality of your sleep; these may include your bedtime routine, habits before bedtime (such as eating, drinking, watching TV), and bedroom environment (light, noise, temperature).

Sometimes a doctor will also recommend a physical exam and additional medical history to determine if other health conditions may be affecting sleep.

If you and your doctor aren’t able to identify a cause of your insomnia, your doctor may recommend a sleep study, or polysomnogram (PSG). A PSG usually requires an overnight stay at a sleep center. During your stay, a PSG records brain electrical activity, eye movements, heart rate, breathing, muscle activity, blood pressure, and blood oxygen levels. The goal is to diagnose an underlying sleep disorder that is causing your insomnia.

Treatment

Treatment for insomnia may start with lifestyle changes, especially to habits and behaviors directly affecting sleep (see “Lifestyle” below for more information). As well, medications are sometimes prescribed to treat insomnia, and over-the-counter (OTC) sleep aids may also be used (find more information under “Medication”).

If other medical conditions may be affecting your ability to sleep or the quality of your sleep, addressing these may help relieve insomnia. A physical exam with your doctor will identify or rule out potential medical causes of insomnia.

Cognitive behavioral therapy (CBT) may be used to treat insomnia. This approach addresses thoughts and actions that prevent or interrupt sleep while encouraging good sleep habits. For example, by teaching patients ways of dealing with worries that keep them awake, they may find it easier to fall and stay asleep. CBT may involve one-on-one consultations with a therapist or group sessions. The following approaches may also be used as part of CBT:

  • Sleep hygiene—efforts to improve habits that allow and encourage better sleep; examples include setting regular bedtime and wake-up times, not smoking, avoiding alcohol and caffeine late in the day, and getting regular exercise
  • Sleep restriction—going to bed later and waking up earlier in an effort to limit time spent in bed not sleeping; time in bed is gradually increased until you are sleeping all night (In other words, you maximize the time spent in bed actually sleeping rather than lying awake.)
  • Stimulus control—conditioning a positive association with going to bed; this is done by using the bed only for sleep and sex
  • Relaxation training—using methods like meditation, hypnosis, and muscle relaxation to reduce stress and body tension
  • Remaining passively awake—trying not to fall asleep in order to stop worries about falling asleep

Lifestyle

These lifestyle measures may help you sleep better:

  • Go to bed at the same time each night and get up at the same time each morning.
  • Avoid naps late in the afternoon, such as after 3 p.m.
  • Exercise regularly. Don’t exercise, however, too late in the day—as activity close to bedtime may make it difficult to fall asleep.
  • Eat dinner two or three hours before you plan to go to bed.
  • Make sure your bedroom is dark, cool, and quiet. If the room isn’t dark or quiet enough, try an eye mask or earplugs.
  • Establish a relaxing bedtime routine. Examples include taking a bath, listening to music, or reading a book.
  • Don’t lie in bed for more than 20 minutes if you can’t fall asleep. Try getting out of bed, sitting in a comfortable place, and doing a quiet activity such as reading until you feel sleepy.
  • If you find yourself lying away and worrying about things you have to do, considering making a to-do list before you go to bed.
  • Use your bed only for sleeping and sex. Do not read extensively, work, or watch TV in bed.

Medications

Medications for insomnia are available by prescription and over the counter. Talk with your doctor about the type of medication that may be right for you. Even if you are considering over-the-counter (OTC) sleep aids, it’s important to consult your doctor; you’ll want to discuss side effects associated with these medications as well as address medical issues that may be affecting your sleep.

Basic guidelines for using any medication to relieve sleeplessness include: using the medication only as directed by your doctor and taking only the prescribed dose; not driving or performing other activities that require you to be alert; telling your doctor about other medications you are using; calling your doctor immediately if you have problems related to the medication; avoiding alcohol and drugs; and talking to your doctor about how to stop using the medication.

Prescription Sleep Medication

Doctors sometimes prescribe medication for insomnia. In many cases, prescription sleep medicines are used for short periods, though they may be used longer for treatment of severe chronic insomnia.

Prescription sleep medications are often helpful in the treatment of insomnia, but it’s important to know about the risks associated with these drugs. They can become habit forming; may mask a medical problem causing insomnia and thus delay treatment; can interact poorly with other medications; and can cause grogginess or even worsen insomnia. The following less common but serious side effects are also associated with sleep medicines: severe allergic reactions, facial swelling, high blood pressure, dizziness, weakness, nausea, confusion, short-term memory loss, and sleep-related behaviors such as binge eating or driving while asleep. Talk with your doctor about any side effects you experience while taking prescription sleep medication.

Over-the-counter Sleep Aids

Over-the-counter sleep aids may help relieve occasional sleeplessness. They are, however, not recommended for regular or long-term use. As well, OTC sleep aids are associated with certain risks: many contain antihistamines, which are not safe for some people, and they can cause side effects including dry mouth, dizziness, and grogginess.

Additional OTC sleep aids include dietary supplements such as melatonin and valerian. Be aware, however, that dietary supplements are not monitored for safety or effectiveness by the U.S. Food and Drug Administration. As a safety precaution, it’s therefore important to discuss use of dietary supplements as sleep aids with your doctor, just as you would prescription or OTC medicines.

Resources

National Center on Sleep Disorders Research
NHLBI Health Information Center

American Insomnia Association

National Sleep Foundation

SOURCES

Insomnia. National Heart Lung and Blood Institute Web site.  Available at:http://www.nhlbi.nih.gov/health/dci/Diseases/inso/inso_whatis.html. Accessed August 2010.

Insomnia. Womenshealth.gov. Available at:http://www.womenshealth.gov/faq/insomnia.cfm#g.

Accessed August 2010.