- Things to Know
- Signs & Symptoms
- Who Gets It?
- Diagnostic Tests
- Home Remedies
Things to know about insomnia
- Insomnia is a condition characterized by poor quality and/or quantity of sleep, despite adequate opportunity to sleep, which leads to daytime functional impairment.
- Many diseases, syndromes, and psychiatric conditions may be responsible for causing insomnia.
- Some common signs and symptoms of insomnia include the following:
- Sometimes insomnia may be unrelated to any underlying condition.
- There are several useful non-medical behavioral techniques available for treating the problem.
- Medications are widely used to treat insomnia in conjunction with non-medical strategies.
- Sleep specialists are doctors who can play an important role in evaluating and treating long-standing (chronic) insomnia.
What is insomnia?
Insomnia is defined as difficulty initiating or maintaining sleep, or both, despite adequate opportunity and time to sleep, leading to impaired daytime functioning. Insomnia may be a cause of or result of poor quality and/or quantity of sleep.
Insomnia is very common. Ninety percent of the general population has experienced acute insomnia at least once. Approximately 10% of the population may suffer from chronic (long-standing) insomnia.
The problem affects people of all ages including children, although it is more common in adults and its frequency increases with age. In general, women are affected more frequently than men.
What are the types of insomnia?
Insomnia may be divided into three types based on the duration of symptoms.
- Transient insomnia lasts 1 week or less and may be termed transient insomnia.
- Short-term insomnia lasts more than 1 week but resolves in less than 3 weeks.
- Long-term or chronic insomnia lasts more than 3 weeks.
Insomnia can also be classified based on the underlying reasons for insomnia:
It's important to make a distinction between insomnia and other similar terminology; short duration sleep and sleep deprivation.
- Short-duration sleep may be normal in some patients who may require less time for sleep without feeling daytime impairment, the central symptom in the definition of insomnia.
- Sleep deprivation: In insomnia, adequate time and opportunity for sleep are available, whereas, in sleep deprivation, lack of sleep is due to a lack of opportunity or time to sleep because of voluntary or intentional avoidance of sleep.
What are the signs and symptoms of insomnia?
Impairment of daytime functioning is the defining and the most common symptom of insomnia.
Other common insomnia symptoms include the following:
Who gets insomnia?
There are no specific risk factors for insomnia because of the variety of underlying causes that may lead to insomnia. The medical and psychiatric conditions listed earlier may be considered risk factors for insomnia if untreated or difficult to treat. Some of the emotional and environmental situations that were also mentioned above may act as risk factor for insomnia.
What causes insomnia?
Insomnia may have many causes and, as described earlier, it can be classified based upon the underlying cause. The International Classification of Sleep Disorders, has classified insomnia into multiple categories:
- Adjustment insomnia (acute insomnia): short-term or acute insomnia usually do to stress or environmental changes
- Psychophysiologic insomnia (primary insomnia): prolonged stress with chronic insomnia
- Paradoxical insomnia: little or no sleep at nights with rare normal night sleep because of a pattern of consciousness throughout the night, or where near constant awareness of environmental stimuli occurs
- Insomnia due to a medical condition: insomnia associated with disorders such as advanced chronic obstructive pulmonary disease (COPD), arthritis, cancer, renal disease, fibromyalgia, neurologic problems, Parkinson's disease, and chronic fatigue syndrome
- Insomnia due to mental disorder: depression, schizophrenia, and maniac phase of bipolar illness, for example
- Insomnia due to drug or substance abuse: for example, alcohol abuse, stimulant abuse, caffeine abuse
- Insomnia not due to substances or known physiologic conditions, unspecified: temporary diagnostic term used for suspected but unproven underlying mental, physiological, or environmental problems
- Inadequate sleep hygiene: proper sleep scheduling, routine use of alcohol, nicotine, caffeine, frequent daytime napping, using the bed for watching TV, snacking, or reading and/or studying for tests or work-related subjects
- Idiopathic insomnia: long-term insomnia begun in infancy or childhood with no readily identifiable underlying cause
- Behavioral insomnia of childhood: insomnia in children based on adult caregiver observations
- Primary sleep disorders causing insomnia: insomnia due to restless leg syndrome, obstructive sleep apnea/hypopnea (shallow breathing) syndrome, nocturia (need to urinate at night), or circadian rhythm disorders for example
Insomnia caused by stress and lifestyle factors
Common situational and stress factors leading to acute or adjustment insomnia may include the following:
- Jet lag
- Physical discomfort (hot, cold, lighting, noise, unfamiliar surroundings)
- Working different shifts
- Stressful life situations (divorce or separation, death of a loved one, losing a job, preparing for an examination)
- Illicit drug use
- Cigarette smoking
- Caffeine intake prior to going to bed
- Alcohol intoxication or withdrawal
- Certain medications
Most of these factors may be short-term, transient, and controllable or modifiable by actions a patient decides to take, and therefore insomnia may resolve in many patients when the underlying factor is removed or corrected.
When should I call the doctor or other health care professional if I can't sleep?
In general, acute insomnia related to transient situational factors resolves spontaneously when the provoking factor is removed or corrected. However, medical evaluation by a doctor may be necessary if the insomnia persists or it is thought to be related to a medical or a psychiatric condition. Many people choose not to discuss their insomnia symptoms with their doctor; however, individuals should contact their doctor if insomnia is interfering with daytime activities.
There are also specialized doctors who evaluate and treat insomnia and other sleep disorders. Sleep apnea may be evaluated by board-certified sleep physicians from varying backgrounds who have specialized in sleep disorders. Other doctors who evaluate and treat sleep disorders are neurologists with a specialty in sleep disorders.
Is there a test to diagnose the condition?
Evaluation and diagnosis of insomnia may start with a thorough medical and psychiatric patient history taken by the doctor or other health care professional. As mentioned previously, many medical and psychiatric conditions can be responsible for insomnia.
A doctor will examine the patient to assess for any abnormal findings as well. Portions of the exam may include the following:
- Assessment of mental status and neurological function
- Heart, lung, and abdominal exam
- Ear, nose, and throat exam
- Measurement of the neck circumference and waist size.
- Questions about any routine medications you are currently taking, and the use of any illegal drugs, alcohol, tobacco, or caffeine.
Laboratory or blood work pertinent to these conditions can also be a part of the assessment.
Sleep patterns: The patient's family members and bed partners also need to be interviewed to ask about the patient's sleep patterns, snoring, or movements during sleep.
Sleep habits: Specific questions regarding sleep habits and patterns are also a vital part of the assessment. Asleep history focuses on:
- Duration of sleep
- Time of sleep
- Time to fall asleep
- Number and duration of awakenings
- Time of final awakening in the morning
- Time and length of any daytime naps
- The typical sleep environment
Sleep logs or diaries: Sleep logs or diaries may be used for this purpose to record these parameters on a daily basis for a more accurate assessment of your sleep patterns.
Sleep history: Sleep history also typically includes questions about possible symptoms associated with insomnia. You may be asked about daytime functioning, fatigue, concentration and attention problems, naps, and other common symptoms of the condition.
Other diagnostic tests may be done as part of the evaluation for insomnia, although they may not be necessary for all patients with insomnia.
Polysomnography is a test that is done in sleep centers if medical conditions such as sleep apnea are suspected. In this test, the person will be required to spend a full night at the sleep center while being monitored for heart rate, brain waves, respiration, movements, oxygen levels, and other parameters while they are sleeping. The data is then analyzed by a specially trained physician to diagnose or rule out sleep apnea or other disorders of sleep.
Actigraphy is another more objective test that may be performed in certain situations but is not routinely a part of the evaluation for insomnia. An actigraph is a motion detector that senses the person's movements during sleep and wakefulness. It is worn like a wristwatch for days to weeks, and the movement data are recorded and analyzed to determine sleep patterns and movements. This test may be useful in cases of primary insomnia disorder, circadian rhythm disorder, or sleep state misconception. Many commercially available devices are popular today for patients to use on their own and track their sleep patterns. The majority of these devices have not been evaluated against the gold standard devices and methods. Their role in identifying true insomnia has yet to be established in the scientific literature.
What are the treatments for insomnia?
The treatment of insomnia depends largely on the cause of the problem. In cases where an obvious situational factor is responsible for the insomnia, correcting or removing the cause generally cures the problem. For example, if insomnia is related to a transient stressful situation, such as jet lag or an upcoming examination, it will then be cured when the situation resolves.
Generally speaking, the treatment of insomnia can be divided into non-medical or behavioral approaches and medical therapy. Both approaches are necessary to successfully treat the problem, and combinations of these approaches may be more effective than either approach alone.
When it's related to a known medical or psychiatric condition, then appropriate treatment of that problem is in the forefront of therapy for insomnia in addition to the specific therapy for insomnia itself. Without adequately addressing the underlying cause, insomnia will likely go on despite taking aggressive measures to treat it with both medical and non-medical therapies.
Natural and home remedies to cure insomnia
There are several recommended techniques used in treating people with insomnia. These are non-medical strategies and are generally advised to be practiced at home in combination with other remedies for insomnia, such as medical treatments for insomnia and treatment for any underlying medical or psychiatric disorders.
Some of the most important of these behavioral techniques are sleep hygiene, stimulus control, relaxation techniques, and sleep restriction. Behavioral sleep specialists may also be available in some clinics and can be very helpful in managing the non-medical treatment options. They may use additional techniques dealing with cognitive behavioral therapy, including some biofeedback methods that help patients with insomnia relax and transition to sleep. They also may recommend you keep a sleep diary.
Sleep hygiene is one of the components of non-medical treatments for insomnia, and includes simple steps that may improve the initiation and maintenance of sleep. Sleep hygiene consists of the following strategies:
- Sleep as much as possible to feel rested, then get out of bed (do not over-sleep).
- Maintain a regular sleep schedule. Go to bed and wake up at the same time daily.
- Do not force yourself to sleep.
- Do not drink caffeinated beverages or other stimulants in the afternoon or evening.
- Do not drink alcohol prior to going to bed.
- Do not smoke, especially in the evening.
- Adjust the bedroom environment to induce sleep.
- Avoid watching television in bed and for 30 minutes before bed.
- Do not go to bed hungry, but avoid foods that may cause reflux.
- Resolve stress and anxiety before going to bed.
- Exercise regularly, but not 4-5 hours prior to bedtime.
Stimulus control refers to techniques used to help with initiating sleep. These techniques are used to induce an environment in the bedroom that promotes sleep. Some simple steps include:
- Use the bed only for having sex and sleeping, not working, reading, watching TV, eating, or other mentally stimulating activities.
- Go to bed only when you feel ready to sleep.
- Turn off the lights and all the noise in and around the bedroom.
- Get up at the same time every morning to avoid over-sleeping.
- If you do not fall asleep longer than 20 minutes after going to bed, get up and try some relaxation techniques until you are ready to sleep again.
Relaxation techniques, which are also a part of non-medical therapy for insomnia, involve sitting or lying comfortably and relaxing muscles of the body in one area at time. This may be combined with deep, relaxed breathing to promote further body relaxation.
Sleep restriction refers another non-medical behavioral therapy for insomnia which involves limiting the time spent in bed for sleeping only. Many people with insomnia may stay in bed for a long time after they wake up in the morning. This over-sleeping may disrupt the circadian rhythm and make sleep initiation more difficult the following night.
Sleep dairies or logs are used to record the actual time spent sleeping each night, and the time spent in bed is gradually reduced to the exact time spent sleeping by shortening the total time in bed. This method gradually reduces and eliminates over-sleeping over a period of time. It also increases the drive to sleep and makes sleep more efficient, as the time spent in bed approximates the duration of sleep.
Benzodiazepine, non-benzodiazepine, and antidepressant medications to cure insomnia
The main classes of medications used to treat insomnia are the sedatives and hypnotics, such as benzodiazepines and non-benzodiazepine sedatives.
Several medications in the benzodiazepine class have been used successfully for the treatment of insomnia, and the most common ones include
- quazepam (Doral),
- triazolam (Halcion),
- estazolam (ProSom),
- temazepam (Restoril),
- flurazepam (Dalmane), and
- lorazepam (Ativan).
Non-benzodiazepine sedatives are also used commonly for the treatment of insomnia and include most of the newer drugs. Some of the most common ones are
- zaleplon (Sonata),
- zolpidem (Ambien or Ambien CR [note that as of January 1, 2014 the FDA changed the recommended dosage and precautions], Zolpimist, Intermezzo), and
- eszopiclone (Lunesta).
Some anti-depressants (for example, trazodone [Desyrel], amitriptyline [Elavil, Endep], doxepin [Sinequan, Adapin]) can be used effectively to treat insomnia in patients who also may suffer from depression. Some anti-psychotics have been used to treat insomnia, although their routine use for this purpose is generally not recommended.
Melatonin, Rozerem, and Belsomra for problems sleeping
Melatonin: a chemical released from the brain which induces sleep, has been tried in supplement form for treatment of insomnia as well. It has been generally ineffective in treating common types of insomnia, except in specific situations in patients with known low levels of melatonin. Melatonin may be purchased over-the-counter (OTC without a prescription).Suvorexant (Belsomra): is a drug that belongs to a fairly new classification of medications for treating insomnia. It acts by decreasing the activity on orexin receptors in the wake system (lateral hypothalamus) of our brain, rather than increasing the activity in the sleep centers of our brain. The medication is an orexin antagonist. It is thought to be generally safe and well tolerated, but some patients may have side effects.
Antihistamines: There are also other medications that are not in the sedative or hypnotic classes, which have been used in the treatment of insomnia. Sedative antihistamines, diphenhydramine (Benadryl) have been used as sleep aids because of their sedative effects. However, this is not a recommended use of these or other similar drugs due to many side effects and long-term drowsiness the following day.
A doctor or sleep specialist is the best person to discuss these different medications and to decide which one may be the best for each specific individual. Many of these drugs have the potential for abuse and addiction and need to be used with caution. Several of these medications cannot be taken without the supervision of the prescribing doctor.
Is there a cure for insomnia?
Insomnia overall has a favorable outlook. Many cases of insomnia are related to transient situational stresses and are easily reversed when the situation is resolved. In cases of long-standing (chronic) insomnia, any medical or psychiatric cause needs to be assessed and treated. Medical and non-medical home remedies are available for treating insomnia and are generally successful. Combinations of non-medical and medical therapy are usually the most successful. Medical treatment for insomnia without addressing the underlying cause of a person's insomnia will often result in long-term medication use with no resolution of the underlying cause.
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American Academy of Sleep Medicine. "Practice Guidelines."
Insomnia. In: American Academy of Sleep Medicine. The International Classification of Sleep Disorders. 2nd ed. Westchester, Illinois: American Academy of Sleep Medicine; 2005:1-31.
Past contributing medical author: Siamak T. Nabili, MD, MPH