Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep, difficulty maintaining sleep, or waking too early in the morning. These result in the feeling that sleep is not restorative and often are associated with impaired function during the day.
Insomnia is the most common sleep disorder in the United States. About one-third of the adult population has experienced it at some time and approximately 10% have a persistent problem.
Insomnia can be classified in terms of its duration: transient, short-term, and chronic. Transient and short-term insomnia are caused by similar factors, but short-term insomnia usually requires a greater disturbance.
Transient insomnia can be described as lasting from one night to a few weeks and is usually caused by events that alter your normal sleep pattern, such as traveling or sleeping in an unusual environment (e.g., a hotel).
Short-term insomnia lasts about two to three weeks and is usually attributed to emotional factors such as worry or stress.
Chronic insomnia occurs most nights and lasts a month or more.
Typically, transient or short-term insomnia are caused by similar factors, but the degree of disturbance is usually greater to experience short-term insomnia. These include:
- Stress-related factors – significant personal events, such as losing a job, marital problems, stress and generaly worrying.
- Uncomfortable sleeping environment (too much light or noise, uncomfortable temperature).
- Unusual sleeping environment (e.g., a hotel room).
- Changes in the daily rhythm, such as a change in work shift or jet lag.
- Acute medical illness or their treatments.
Chronic insomnia may be caused by one of the following:
- Chronic medical illnesses - Certain medical illness can interfere with sleep, especially disorders of the heart (congestive heart failure) and lungs (chronic obstructive pulmonary disease). Other important physical causes include heartburn, prostatism, menopause, diabetes, arthritis, hyperthyroidism and hypoglycemia.
- Sleep disordered breathing - Disorders of sleep that cause one to stop breathing while asleep may fragment sleep and cause frequent awakenings during the night. This can be seen rarely with obstructive sleep apnea, but is much more common with central sleep apnea.
- Restless leg syndrome (RLS) – RLS is an unpleasant tickling, burning, pricking or aching sensations in the legs that are generally only relieved with movement and tend to occur while relaxing in the evening hours. A similar and often overlapping disorder is periodic limb movement of sleep, which are the recurrent movements of the legs during sleep that may cause arousals from sleep.
- Psychophysiologic ("learned") insomnia - Many people go to bed worrying about insomnia because of previous episodes. This creates an anxiety about going to sleep, which usually leads to greater difficulty sleeping.
- Biological factors - As we age, sleep becomes lighter and more fragmented. Older people often struggle with frequent nighttime awakenings and the inability to sleep past the very early morning. Also, during our life spans, the internal biological "clock" that regulates sleep creeps slightly forward, compelling most older people to go to sleep earlier and to wake earlier.
- Lifestyle factors - Excessive caffeine consumption, alcohol and drug abuse, smoking, and poor sleeping habits are often overlooked as cause of chronically disturbed sleep.
Surprisingly, a sleep study is not routinely recommended for those complaining of insomnia. The reason is that when a sleep study is performed in someone suffering from insomnia, it does not generally give any new information; it simply confirms that the patient is having trouble sleeping. The best way to find the cause for insomnia is by careful history taking. Assessment of recent onset insomnia should focus on acute personal and medical problems. In those reporting long-term sleep disturbances, evaluation should address the history as well as physical and mental status. Referral to a sleep laboratory might be appropriate if a sleep-related breathing disorder is suspected, insomnia has been present for more than six months and medical, psychiatric, and neurological causes have been excluded, or if insomnia has not responded to medical or behavioral treatment. Additionally, a sleep diary should be maintained. This diary would include bedtimes, estimates of the time needed to fall asleep, number of night awakenings, and total amount of time asleep. This helps in correct diagnosis as well as monitoring the treatment.
When people think of treatment for insomnia they tend to think of sleeping pills, but there are actually non-medical therapy that have not only been shown to be effective in improving insomnia, but are possibly even better in the long term than “sleeping pills”. Insomnia therapy can be divided into two areas: treatment with and without medication.
Treatment with Medication
- Alcohol. Commonly self-prescribed as a sleep aid, alcohol is of limited benefit. A very small amount of alcohol can be relaxing and produce sleepiness early in the evening, but later in the evening there may be a “rebound effect” of difficulty sleeping. In addition, chronic alcohol use can produce tolerance and dependence and cause many other medical problems.
- Antihistamines. Usually sold as remedies for colds, over-the-counter antihistamines (e.g., diphenhydramine) can produce sedation and are often used as sleeping pills. These agents can be effective for short-term use, but they have not been shown to be consistently effective. Since they are long acting medications, grogginess can persist into the daytime.
- Benzodiazepines. These drugs, relatives of diazepam (Valium), improve sleep by decreasing the amount of time needed to fall asleep and the number of awakenings during sleep. Their use has declined considerably with the introduction of non-benzodiazepine drugs (see below). The side effects of using these drugs are poor coordination, reduced reaction time, and impaired memory. These "hangover effects" occur when the blood level is at its peak and will vary depending on how long the drug remains in the body. These drugs may also worsen sleep apnea.
- Non-benzodiazepines - These drugs have been introduced over the past 10-12 years and have become the primary treatment for short-term insomnia. They work in the same area of the brain as the BZDs, but tend to be more specific for inducing sleep. They also do not cause significant hangover effects and do not seem to worsen sleep apnea. Examples of this class of drugs are Ambien, Sonata, and Lunesta.
- Ramelteon (Rozerem) - A newly approved medication that acts at the melatonin receptor to help induce sleep (see below).
- Melatonin - This herbal agent seems to be effective in helping transient and short-term insomnia. However, as an herbal supplement which is not regulated by the Food and Drug Administartion, there is a great discrepancy in the quality of the products and no firm recommendations and can be given for its use.
- Antidepressants - These agents are often prescribed as sleep aids in those with co-existing psychiatric problems. The most commonly used sedating antidepressant is trazodone.
- Herbal medications such as valerian, chamomile, and kava-kava, are often used to help sleep, but long-term effectiveness and safety data are not available.
Treatment without Medication
The non-medication treatment methods used to help insomnia are often focused at helping the patient “relearn” how to sleep. Some of these techniques are common-sense habits that go a long way in helping people feel sleepy at night. These include:
- Develop a regular sleeping schedule. Avoid daytime naps and stimulating activities just before bedtime.
- Avoid stimulating drugs, such as caffeine and nicotine, particularly before going to bed.
- Exercise during the day (but not in the late evening).
- Avoid alcohol- it is a leading cause of poor sleep.
- Minimize light and noise when trying to sleep..
- Maintain a comfortable bedroom temperature.
- Avoid heavy meals before bedtime. If hungry, eat a light carbohydrate snack.
- Take medications that may be stimulating, or those that may cause you to wake up to urinate long before bedtime.
- Increase exposure to sunlight in the morning, and avoid it later in the afternoon (5-6 PM).
Additionally, there are some behavioral techniques, usually conducted under the guidance of a psychologist, that can be very helpful in treating insomnia. The effectiveness of these procedures tends to be more durable in helping patients with insomnia than treatment with medication alone. These include relaxation therapy, sleep restriction, stimulus control, and cognitive therapy.
Relaxation therapy consists of techniques that help reduce or eliminate anxiety and body tension.
Sleep restriction is a technique that starts with a person only being allowed to get a few hours sleep a night; over time the hours of sleep are increased until a more normal night's sleep is achieved. This technique is designed to limit the hours that one spends in bed unable to sleep and helps re-associate the bedroom with sleeping, instead of the frustration of insomnia.
Stimulus control therapy attempts teach the patient to use the bedroom is only for activities related to sleep. For most people this means not using their beds for any activities other than sleep and sex.
The goal of cognitive therapy is provide reassurance to patients that sleeping less than 8 hours a night is not necessarily unhealthy and does not always lead to major consequences on the following day.
What kind of insomnia is it?
What will the body do if it is not getting enough sleep?
What over-the-counter sleeping aids do you recommend?
How long can a person safely take sleeping pills?
Will you be prescribing any medication?
What are the side effects?
What other measures can be done to help me sleep better?