Insomnia

Insomnia is a disruption in an individual’s sleep quality, timing and duration of sleep hours. These sleep pattern conditions negatively impact overall health. In addition to insomnia, other examples of sleep disorders are narcolepsy, restless leg syndrome (RLS) and sleep apnea.

Sleep-related difficulties affect many people. If you, or someone you know, is experiencing any symptoms of insomnia or other sleep disorders, it is important to receive an evaluation by a healthcare provider or, if necessary, a provider specializing in sleep medicine.

Insomnia is characterized by an inability to initiate or maintain sleep. It may also take the form of early morning awakening in which the individual awakens several hours early and is unable to resume sleeping. Difficulty initiating or maintaining sleep may often manifest itself as excessive daytime sleepiness, which characteristically results in functional impairment throughout the day.

Insomnia is typically classified by duration. Chronic insomnia lasts six months or longer, short-term insomnia lasts between one and six months, and transient insomnia lasts one month or less. There are five types of insomnia:

1. Acute Insomnia: Acute insomnia typically lasts from one night to several weeks. It is characterized by an individual having trouble falling asleep and/or staying asleep.
2. Behavioral Insomnia of Childhood: Children as young as six months old may experience behavioral insomnia of childhood, which is seen in as many as 30 percent of children. Children with this condition have trouble having a hard time falling asleep on their own. Children may also use stalling tactics or show resistance to falling asleep, or returning to sleep upon waking in the night. Many children have a combination of any or all of these symptoms.
3. Chronic Insomnia: Chronic (long-term) insomnia occurs three or more nights a week, lasts more than three months and cannot be fully explained by another health problem.
4. Onset Insomnia: Onset insomnia refers to individuals who experience difficulty initiating sleep even when they feel ready. It is often triggered by lifestyle changes, bad habits (including too much screen time close to bedtime) or other life stressors.
5. Maintenance Insomnia: When someone struggles to stay asleep or wakes too early and cannot fall back to sleep, they may be struggling with maintenance insomnia.

Before arriving at a diagnosis of insomnia, the healthcare provider will rule out other potential causes, such as other sleep disorders, side effects of medications, substance abuse, depression or other previously undetected illness.

Chronic psychophysiological insomnia (or “learned” or “conditioned” insomnia) may result from a stressor combined with fear of being unable to sleep. Individuals with this condition may sleep better when not in their own beds. Healthcare providers may treat chronic insomnia with a combination of use of sedative-hypnotic or sedating antidepressant medications, along with behavioral techniques to promote regular sleep.

Research has found that insufficient sleep is linked to an increased risk for the development of type 2 diabetes. Specifically, sleep duration and quality have emerged as predictors of levels of hemoglobin A1c, an important marker of blood sugar control. Recent research suggests that optimizing sleep duration and quality may be important means of improving blood sugar control in persons with type 2 diabetes.

Persons with sleep apnea have been found to be at increased risk for a number of cardiovascular diseases. Notably, hypertension, stroke, coronary heart disease and irregular heartbeats (cardiac arrhythmias) have been found to be more common among those with disordered sleep than their peers without sleep abnormalities. Likewise, sleep apnea and hardening of the arteries (atherosclerosis) appear to share some common physiological characteristics, further suggesting that sleep apnea may be an important predictor of cardiovascular disease.

Laboratory research has found that short sleep duration results in metabolic changes that may be linked to obesity. Epidemiologic studies conducted in the community have also revealed an association between short sleep duration and excess body weight. This association has been reported in all age groups, but has been particularly pronounced in children. It is believed that sleep in childhood and adolescence is particularly important for brain development and that insufficient sleep in youngsters may adversely affect the function of a region of the brain known as the hypothalamus, which regulates appetite and the expenditure of energy.

The relationship between sleep and depression is complex. While sleep disturbance has long been held to be an important symptom of depression, recent research has indicated that depressive symptoms may decrease once sleep apnea has been effectively treated and sufficient sleep restored. The interrelatedness of sleep and depression suggests it is important that the sleep sufficiency of persons with depression be assessed and that symptoms of depression be monitored among persons with a sleep disorder.

Sleep disorders like insomnia are also often linked to medical conditions, genetics, aging, diet and an irregular schedule. Changes in your schedule or environment can cause or raise your risk of insomnia.

Some risk factors, such as your job or lifestyle, can be changed. But your age and family history cannot be changed. Risk factors that contribute to increased risk in developing sleep problems like insomnia include:

• Age: You can develop insomnia at any age, but your chances of having it increase as you get older.
• Family history and genetics: Your genes may raise your risk of insomnia, as insomnia sometimes runs in families. Your genes may also affect whether you are a deep or light sleeper.
• Environment or occupation: The following can disturb your sleep-wake cycle, a pattern that your body uses to figure out when to sleep and when to be awake:
  • Shift or night work
  • Noise or light during the night
  • Uncomfortably high or low temperatures
• Traveling often to different time zones
• Lifestyle: Habits can raise your risk of sleep problems.
  • Changing your normal routine often, including your sleep schedule
  • Experiencing interruptions in your sleep, such as waking up often to care for a baby
  • Taking long naps during the day
  • Getting too little physical activity during the day
  • Using caffeine, nicotine, alcohol or recreational drugs
  • Watching TV or using electronic devices close to your bedtime
• Stress: Stress or worrying about school or work, relationships, money or the death of a loved one raises your risk of insomnia. Worrying about whether you will get enough sleep and watching the clock can also raise your risk of insomnia or make it worse.
• Gender: Insomnia is more common in women than in men. Hormone changes that take place during pregnancy and menopause often cause problems with sleep.

You may be diagnosed with insomnia if you have difficulty falling or staying asleep for at least three nights a week. Insomnia is considered chronic (long-term) when it occurs three or more nights a week and lasts for three months or longer. Your doctor may do more tests to see whether your insomnia is causing any other health problems.

It may be helpful to keep a sleep diary for one to two weeks before seeing your doctor. A sleep diary can help your doctor understand the problems you’re having and whether certain activities are affecting your sleep. Write down when you go to sleep, wake up and take naps each day. Also write down how sleepy you feel throughout the day, when you drink caffeine or alcohol, and when you exercise.

Screening for sleep disorders such as insomnia involves participating in a sleep study using surveillance systems to monitor sleep duration and quality.

You might also complete a questionnaire that asks the following questions:

• On average, how many hours of sleep do you get in a 24-hour period?
• Over the past two weeks, how many days have you had trouble falling asleep or staying asleep?
• Over the past two weeks, how many days did you unintentionally fall asleep during the day?
• Have you ever been told that you snore loudly?
• Has anyone ever observed that you stop breathing during your sleep?

Signs of insomnia are disrupted sleep, an irregular wake cycle and general sleep challenges (falling asleep and staying asleep). Sleep-disordered individuals appear sleepy and unrested during the day. 

Those with insomnia awaken several hours early and are unable to resume sleeping. Difficulty initiating or maintaining sleep may often manifest itself as excessive daytime sleepiness, which characteristically results in functional impairment throughout the day. Keep a sleep diary, or a record of any symptoms of insomnia you might be experiencing. Share these notes with a healthcare professional.

If you have insomnia, you may experience several different symptoms, including:

• You may lie awake for a long time before you fall asleep. This is more common in younger adults.
• Sleep may be possible for only short amounts of time. You may wake up often during the night or be awake for most of the night. This is the most common symptom and affects mostly older adults.
• Waking up too early in the morning and not getting back to sleep is also common.
• Poor-quality sleep may lead you to wake up feeling unrested, and you may feel sleepy during the day. You may also have trouble focusing on daily tasks. Insomnia can cause you to feel anxious, depressed or easily annoyed. 

In addition to conducting a physical exam, your physician will review your medical and sleep histories. You might also complete a questionnaire that asks the following questions:

• On average, how many hours of sleep do you get in a 24-hour period?
• Over the past two weeks, how many days have you had trouble falling asleep or staying asleep? 
• Over the past two weeks, how many days did you unintentionally fall asleep during the day?
• Have you ever been told that you snore loudly?
• Has anyone ever observed that you stop breathing during your sleep?

Screening for sleep disorders like insomnia often involves participating in a sleep study using surveillance systems to monitor sleep duration and quality. These studies may also be helpful in ruling out other sleep disorders, including narcolepsy, restless leg syndrome (RLS) and sleep apnea. By using electrodes connected to your body, sleep studies monitor your whole system during a full night’s sleep, collecting the following data:

• Breathing rate
• Blood pressure
• Heart rate
• Changes in brain waves
• Eye movements
• Electrical activity of the heart and muscles

Other diagnostic tests that may be performed include:

• Actigraphy: A home-testing process that looks at your periods of rest and activity and measures how well you sleep. This requires you to wear a small motion sensor on your wrist for 3 to 14 days.
• Blood tests: Your doctor may check for thyroid problems or other medical conditions that can affect sleep.

You can take steps to improve your sleep habits. First, make sure that you give yourself enough time to sleep. With enough sleep each night, you may find that you’re happier and more productive during the day.

To improve your sleep habits, it also may help to:

• Make your bedroom sleep friendly. Sleep in a cool, quiet, dark place. Avoid watching TV or looking at electronic devices, as the light from these sources can disrupt your sleep-wake cycle.
• Go to sleep and wake up around the same time each day, even on the weekends. If you can, avoid night shifts, a schedule that changes or other things that may disrupt your sleep schedule. This can be challenging for new parents or shift workers.
• Avoid caffeine, nicotine and alcohol close to your bedtime. Although alcohol can make it easier to fall asleep, it can cause you to have a sleep that tends to be lighter than normal. This makes it more likely that you will wake up during the night.
• Get regular physical activity during the daytime (at least five to six hours before going to bed). Exercising close to bedtime can make it harder to fall asleep.
• Avoid naps, especially in the afternoon. This may help you sleep longer at night.
• Eat meals on a regular schedule and avoid late-night dinners.
• Limit how much fluids you drink close to bedtime. This may help you sleep longer without having to use the bathroom.
• Learn new ways to manage stress. Follow a routine that helps you wind down and relax before bed. For example, read a book, listen to soothing music or take a hot bath. Your healthcare provider may also recommend other ways to relax, including massage therapy, meditation or yoga. 
• Talk to your healthcare provider about over-the-counter and prescription medicines that may be disrupting your sleep (for example, some cold and allergy medicines).

Light therapy involves sitting in front of a light box, which produces bright light similar to sunlight. Light visors and light glasses may also be effective. Light therapy may help adjust the amount of melatonin your body needs to make to reset your sleep-wake cycle.

To move your sleep and wake times earlier, use the light box when you wake up in the morning. This may also help reduce daytime sleepiness. This method may be used to help treat delayed sleep-wake phase disorder, irregular sleep-wake rhythm disorder and jet lag disorder when you travel east.

To move your sleep and wake times later, use the light box late in the afternoon or early in the evening. This method may be used to help treat advanced sleep-wake phase disorder, shift work disorder and jet lag disorder when you travel west.

Side effects of light therapy may include agitation, eye strain, headaches, migraines and nausea. Ask your healthcare provider before using light therapy if you have an eye condition or use medicines that make you sensitive to light.

Cognitive behavioral therapy for insomnia (CBT-I) is a six- to eight-week treatment plan to help you learn how to fall asleep faster and stay asleep longer. This is usually recommended as the first treatment option for long-term insomnia and can be very effective. CBT-I can be done by a healthcare provider, nurse or therapist; you can do it in person, by telephone or online. It involves the following parts:

• Cognitive therapy helps you feel less nervous about not being able to sleep.
• Relaxation or meditation therapy teaches you how to relax and fall asleep faster.
• Sleep education helps you learn good sleep habits.
• Sleep restriction therapy gives you a specific amount of time to spend in bed, even if you are not able to sleep during this time. With time, this helps you sleep better when you go to bed. Your sleep time can be increased when you start to sleep better.
• Stimulus control therapy helps you have a regular sleep-wake cycle so you can link being in bed with being asleep. This involves going to bed only when you are sleepy, getting out of bed if you cannot sleep, and using your bed only for sleep and sexual activity.

If you are having trouble falling asleep or staying asleep, and improving your sleep habits and other therapies have not helped, your healthcare provider may talk to you about medicines to help you sleep. Many of these medicines have side effects and should not be taken long term.

• Benzodiazepine receptor agonists are medicines such as zolpidem, zaleplon and eszopiclone. Side effects may include anxiety. Rare side effects may include having a severe allergic reaction or doing activities while asleep such as walking, eating or driving.
• Melatonin receptor agonists are medicines such as ramelteon. Side effects can include dizziness and fatigue. Some people experience the rare side effects of doing activities while they are asleep, like walking, eating or driving, or they may have a severe allergic reaction.
• Orexin receptor antagonists such as suvorexant are not recommended for people who have narcolepsy. Rare side effects may include doing activities while asleep such as walking, eating or driving, or not being able to move or speak for several minutes while going to sleep or waking up.
• Benzodiazepines may be prescribed for insomnia if other treatments and medicines have not worked. Talk to your healthcare provider about the side effects of these medicines, which can include dizziness, confusion and muscle weakness. Benzodiazepines can also interact dangerously with other medicines. They can be habit-forming and should be taken for only a few weeks.

Tell your healthcare provider about any over-the-counter (OTC) products that you are taking.

• OTC products that contain antihistamines are sold as sleep aids. Although these products might make you sleepy, talk to your provider before taking them, as antihistamines can be unsafe for some people.
• Melatonin supplements are lab-made versions of the sleep hormone melatonin. Many people take melatonin supplements to improve their sleep. These supplements are not regulated by the U.S. Food and Drug Administration like medicines. Because of this, the doses and purity of these supplements can vary between brands. Talk with your provider about how to find safe, effective melatonin supplements, and also about possible side effects or medicine interactions, especially if you are pregnant or trying to become pregnant. Side effects of melatonin may include excess sleepiness, headaches, high blood pressure, low blood pressure, stomach upsets and worsening symptoms of depression.
• Dietary supplements may help you sleep, but they can also have health risks. Talk to your healthcare provider before using dietary supplements.

The U.S. Food and Drug Administration (FDA) regulates dietary supplements under a different set of regulations than those covering "conventional" foods and medicines. The FDA does not currently review dietary supplement products for safety and effectiveness before they are marketed.

If you are having trouble falling asleep or staying asleep, and improving your sleep habits and other therapies have not helped, your healthcare provider may talk to you about medicines to help you sleep. Many of these medicines have side effects and should not be taken long term.

Some prescription medicines used to treat other health conditions can also increase your risk of developing sleep conditions.

• Benzodiazepine receptor agonists are medicines such as zolpidem, zaleplon and eszopiclone. Side effects may include anxiety. Rare side effects may include having a severe allergic reaction or doing activities while asleep such as walking, eating or driving.
• Melatonin receptor agonists are medicines such as ramelteon. Side effects can include dizziness and fatigue. Some people experience the rare side effects of doing activities while they are asleep, like walking, eating or driving, or they may have a severe allergic reaction.
• Orexin receptor antagonists such as suvorexant are not recommended for people who have narcolepsy. Rare side effects may include doing activities while asleep such as walking, eating or driving, or not being able to move or speak for several minutes while going to sleep or waking up.
• Benzodiazepines may be prescribed for insomnia if other treatments and medicines have not worked. Talk to your healthcare provider about the side effects of these medicines, which can include dizziness, confusion and muscle weakness. Benzodiazepines can also interact dangerously with other medicines. They can be habit-forming and should be taken for only a few weeks.

Tell your healthcare provider about any over-the-counter (OTC) products that you are taking.

• OTC products that contain antihistamines are sold as sleep aids. Although these products might make you sleepy, talk to your provider before taking them, as antihistamines can be unsafe for some people.
• Melatonin supplements are lab-made versions of the sleep hormone melatonin. Many people take melatonin supplements to improve their sleep. These supplements are not regulated by the U.S. Food and Drug Administration like medicines. Because of this, the doses and purity of these supplements can vary between brands. Talk with your provider about how to find safe, effective melatonin supplements, and also about possible side effects or medicine interactions, especially if you are pregnant or trying to become pregnant. Side effects of melatonin may include excess sleepiness, headaches, high blood pressure, low blood pressure, stomach upsets and worsening symptoms of depression.
• Dietary supplements may help you sleep, but they can also have health risks. Talk to your healthcare provider before using dietary supplements.

The U.S. Food and Drug Administration (FDA) regulates dietary supplements under a different set of regulations than those covering "conventional" foods and medicines. The FDA does not currently review dietary supplement products for safety and effectiveness before they are marketed.