Insomnia and Sleep
For more information about Insomnia, visit National Sleep Foundation's official Insomnia hub.
Insomnia, which is Latin for "no sleep," is the inability to fall asleep or remain asleep. Insomnia is also used to describe the condition of waking up not feeling restored or refreshed. According to Dr. Mark Mahowald, Professor of Neurology at the University of Minnesota Medical School and Director of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center, insomnia refers to the inability to get the amount of sleep you as an individual need to wake up feeling rested.
Insomnia is the most common sleep complaint among Americans. It can be either acute, lasting one to several nights, or chronic, even lasting months to years. When insomnia persists for longer than a month, it is considered chronic. According to the National Center for Sleep Disorders Research at the National Institutes of Health, about 30-40% of adults say they have some symptoms of insomnia within a given year, and about 10-15 percent of adults say they have chronic insomnia. People who have trouble sleeping every night without exception for months or years are fairly rare. More often, people experience chronic-intermittent insomnia, which means difficulty sleeping for a few nights, followed by a few nights of adequate sleep before the problem returns.
Insomnia can be a disorder in its own right, but often it is a symptom of some other disease or condition. Half of all those who have experienced insomnia blame the problem on stress and worry. In the case of stress-induced insomnia, the degree to which sleep is disturbed depends on the severity and duration of the stressful situation. Sometimes this may be a disturbing occurrence like loss of a loved one, loss of a job, marital or relationship discord or a tragic occurrence. Anticipation of such things as weddings, vacations, or holidays can also disturb sleep and make it difficult to fall asleep or remain asleep. Insomnia can also occur with jet lag, shift work and other major schedule changes.
If you have difficulty sleeping, it is essential to determine whether an underlying disease or condition is causing the problem. Sometimes insomnia is caused by pain, digestive problems or a sleep disorder. Insomnia may also signal depression or anxiety. Often times, insomnia exacerbates the underlying condition by leaving the patient fatigued and less able to cope and think clearly. For insomnia related to a medical condition or pain, ask your doctor about nighttime pain aids.
If your sleep trouble is confined to difficulty falling asleep, the time you are choosing to go to sleep may not be synchronized with your biological clock. The biological processes that initiate and maintain sleep in humans are active throughout the night. Opposing this sleep tendency, however, is the alerting action of the biological clock that is active throughout the day. When the biological clock is active at your scheduled bedtime, you will have sleep-onset insomnia.
The prevalence of insomnia is higher among older people and women. Women suffer loss of sleep in connection with menstruation, pregnancy, and menopause. Rates of insomnia increase as a function of age but most often the sleep disturbance is attributable to some other medical condition.
Some medications can lead to insomnia, including those taken for:
- colds and allergies
- high blood pressure
- heart disease
- thyroid disease
- birth control
- pain medications
- depression (especially SSRI antidepressants)
Some common sleep disorders such as restless legs syndrome and sleep apnea can also lead to insomnia.
Sleep is as essential as diet and exercise. Inadequate sleep can result in fatigue, depression, concentration problems, illness and injury.
Symptoms of insomnia include:
- difficulty falling asleep
- waking up frequently during the night
- difficulty returning to sleep
- waking up too early in the morning
- unrefreshing sleep
- daytime sleepiness
- difficulty concentrating
Left untreated, insomnia is linked to increased illness or morbidity. There is a wealth of research indicating that people with insomnia have poorer overall health, more work absenteeism, and a higher incidence of depression. Sleep deprivation is not insomnia. It is not actually clear that insomniacs "lose sleep," particularly when it is primary. Many do not exhibit daytime distress or symptoms. Although people with acute insomnia may experience daytime sleepiness, most chronic insomnia patients experience an unpleasant sense of excessive arousal during the daytime.
If you are experiencing difficulty sleeping, consider whether an event or particular stress could be the cause. If so, the problem may resolve in time. If not, and the problem persists for a few weeks or more, or if you experience distress and discomfort as a result of the insomnia, talk to your doctor about your symptoms. Bring with you a record of your sleep, fatigue levels throughout the day, and any other symptoms you might be having.
There are a number of approaches to treating insomnia. A health care professional will ask about your sleep experience, your sleep schedule, and your daily routine. A thorough medical history and physical examination may be called for.
Because of the close connection between behavior and insomnia, behavioral therapy is often part of any treatment for insomnia. This is because people with insomnia may begin to associate certain sleep-related stimuli with being awake. For example, bedtime routines or the bedroom itself may become linked with anxiety for a person who is experiencing insomnia because they dread the thought of another sleepless night. A combination of several behavioral treatments is typically the most effective approach. Some examples of behavioral treatments are:
- Stimulus Control Therapy: creating a sleep environment that promotes sleep
- Cognitive Therapy: learning to develop positive thoughts and beliefs about sleep
- Sleep Restriction: following a program that limits time in bed in order to get to sleep and stay asleep throughout the night
Relaxation techniques, such as yoga, meditation, and guided imagery may be especially helpful in preparing the body to sleep. Exercise, done early in the day, can also be helpful in reducing stress and promoting deeper sleep.
Behavioral therapies alone may not be enough. Treating insomnia with sleep aids is the most common treatment for these sleep problems, particularly once a combination of behavioral approaches has been tried. Sleep medications for the treatment of insomnia are called hypnotics. They should only be taken when:
- The cause of your insomnia has been evaluated
- The sleep problems are causing difficulties with your daily activities
- Appropriate sleep promoting behaviors have been addressed
All hypnotics induce sleep and some will help to maintain sleep. They work by acting at areas in the brain believed to be involved in sleep promotion. They are the drugs of choice because they have the highest benefit and the lowest risk as sleep-promoting drugs. Talk to your doctor about the possible side effects of taking hypnotics, such as morning sedation, memory problems, headaches, sleepwalking and a night or two of poor sleep after stopping the medication.
Women who are pregnant or nursing should not take hypnotics. Talk to your doctor about how to cope with insomnia during this time.
Finally, practicing good sleep hygiene may improve the quality of your sleep.
Regardless of what's causing your sleep problems, it is important to establish and maintain healthy sleep habits. Here are some tips that will help you sleep well:
- Use the bed and bedroom for sleep and sex only
- Establish a regular bedtime routine and a regular sleep-wake schedule
- Do not eat or drink too much close to bedtime
- Create a sleep-promoting environment that is dark, cool and comfortable
- Avoid disturbing noises – consider a bedside fan or white-noise machine to block out disturbing sounds
During the day:
- Consume less or no caffeine, particularly late in the day
- Avoid alcohol and nicotine, especially close to bedtime
- Exercise, but not within three hours before bedtime
- Avoid naps, particularly in the late afternoon or evening
- Keep a sleep diary to identify your sleep habits and patterns that you can share with your doctor
According to NSF polls dating back to 1999, over 1/2 of America’s adults experience one or more symptom of insomnia at least a few nights a week. In 2005, the following percentages of adults reported having the following symptoms this often: 38% woke up feeling unrefreshed; 32% wake often during the night; and 21% of the population reports waking too early, not being able to get back to sleep and difficulty falling asleep. Of this last group, almost 1?4 state that it takes them at least 30 minutes to fall asleep. These people are likely to be women (28% vs. 16%) and not to have a bed partner (27% vs. 19%).
People who drink >4 caffeinated beverages a day are more likely to have difficulty falling asleep and wake unrefreshed. Those who are obese are more likely to have a symptom of insomnia. Adults who have daytime sleepiness at least 3 times a week are experiencing a symptom of insomnia (86%) compared to those who rarely or never have such symptoms (31%). This is also true for those who say sleepiness has a strong impact on their daily activities (83%) versus those who experience very little impact (44%). More people who take >2 naps a day report symptoms of insomnia (62%) compared to those who do not take a nap (48%).
Reviewed by David N. Neubauer, M.D., M.A