INSOMNIA

What are Different Types of Insomnia?

There are multiple ways to describe insomnia:

Acute insomnia

A brief episode of difficulty sleeping. Acute insomnia is usually caused by a life event, such as a stressful change in a person's job, receiving bad news, or travel. Often acute insomnia resolves without any treatment.

Chronic insomnia

A long-term pattern of difficulty sleeping. Insomnia is usually considered chronic if a person has trouble falling asleep or staying asleep at least three nights per week for three months or longer. Some people with chronic insomnia have a long-standing history of difficulty sleeping. Chronic insomnia has many causes.

Comorbid insomnia

Insomnia that occurs with another condition. Psychiatric symptoms — such as anxiety and depression — are known to be associated with changes in sleep. Certain medical conditions can either cause insomnia or make a person uncomfortable at night (as in the case of arthritis or back pain, which may make it hard to sleep.

Onset insomnia

Difficulty falling asleep at the beginning of the night.

Maintenance insomnia

The inability to stay asleep. People with maintenance insomnia wake up during the night and have difficulty returning to sleep.

What Causes Insomnia?

Insomnia can be caused by psychiatric and medical conditions, unhealthy sleep habits, specific substances, and/or certain biological factors. Recently, researchers have begun to think about insomnia as a problem of your brain being unable to stop being awake (your brain has a sleep cycle and a wake cycle—when one is turned on the other is turned off—insomnia can be a problem with either part of this cycle: too much wake drive or too little sleep drive). It's important to first understand what could be causing your sleep difficulties.

How Much Sleep Do You Need?

Medical Causes of Insomnia

There are many medical conditions (some mild and others more serious) that can lead to insomnia. In some cases, a medical condition itself causes insomnia, while in other cases, symptoms of the condition cause discomfort that can make it difficult for a person to sleep.

Examples of medical conditions that can cause insomnia are:

• Nasal/sinus allergies
• Gastrointestinal problems such as reflux
• Endocrine problems such as hyperthyroidism
• Arthritis
• Asthma
• Neurological conditions such as Parkinson's disease
• Chronic pain
• Low back pain

Medications such as those taken for the common cold and nasal allergies, high blood pressure, heart disease, thyroid disease, birth control, asthma, and depression can also cause insomnia.

In addition, insomnia may be a symptom of underlying sleep disorders. For example, restless legs syndrome—a neurological condition in which a person has an uncomfortable sensation of needing to move his or her legs—can lead to insomnia. Patients with restless legs syndrome typically experience worse symptoms in the later part of the day, during periods of inactivity, and in the transition from wake to sleep, which means that falling asleep and staying asleep can be difficult. An estimated 10 percent of the population has restless legs syndrome.

Sleep apnea is another sleep disorder linked to insomnia. With sleep apnea, a person's airway becomes partially or completely obstructed during sleep, leading to pauses in breathing and a drop in oxygen levels. This causes a person to wake up briefly but repeatedly throughout the night. People with sleep apnea sometimes report experiencing insomnia.

If you have trouble sleeping on a regular basis, it's a good idea to review your health and think about whether any underlying medical issues or sleep disorders could be contributing to your sleep problems. In some cases, there are simple steps that can be taken to improve sleep (such as avoiding bright lighting while winding down and trying to limit possible distractions, such as a TV, computer, or pets). While in other cases, it's important to talk to your doctor to figure out a course of action. You should not simply accept poor sleep as a way of life—talk to your doctor or a sleep specialist for help.

Insomnia & Depression

Insomnia can be caused by psychiatric conditions such as depression. Psychological struggles can make it hard to sleep, insomnia itself can bring on changes in mood, and shifts in hormones and physiology can lead to both psychiatric issues and insomnia at the same time.

Sleep problems may represent a symptom of depression, and the risk of severe insomnia is much higher in patients with major depressive disorders. Studies show that insomnia can also trigger or worsen depression.

It's important to know that symptoms of depression (such as low energy, loss of interest or motivation, feelings of sadness or hopelessness) and insomnia can be linked, and one can make the other worse. The good news is that both are treatable regardless of which came first.

Insomnia & Anxiety

Most adults have had some trouble sleeping because they feel worried or nervous, but for some it's a pattern that interferes with sleep on a regular basis. Anxiety symptoms that can lead to insomnia include:

• Tension
• Getting caught up in thoughts about past events
• Excessive worrying about future events
• Feeling overwhelmed by responsibilities
• A general feeling of being revved up or overstimulated

It's not hard to see why these symptoms of general anxiety can make it difficult to sleep. Anxiety may be associated with onset insomnia (trouble falling asleep), or maintenance insomnia (waking up during the night and not being able to return to sleep). In either case, the quiet and inactivity of night often brings on stressful thoughts or even fears that keep a person awake.

When this happens for many nights (or many months), you might start to feel anxiousness, dread, or panic at just the prospect of not sleeping. This is how anxiety and insomnia can feed each other and become a cycle that should be interrupted through treatment. There are cognitive and mind-body techniques that help people with anxiety settle into sleep, and overall healthy sleep practices that can improve sleep for many people with anxiety and insomnia.

Insomnia & Lifestyle

Insomnia can be triggered or perpetuated by your behaviors and sleep patterns. Unhealthy lifestyles and sleep habits can create insomnia on their own (without any underlying psychiatric or medical problem), or they can make insomnia caused by another problem worse.

Examples of how specific lifestyles and sleep habits can lead to insomnia are:

• You work at home in the evenings. This can make it hard to unwind, and it can also make you feel preoccupied when it comes time to sleep. The light from your computer could also make your brain more alert.
• You take naps (even if they are short) in the afternoon. Short naps can be helpful for some people, but for others they make it difficult to fall asleep at night.
• You sometimes sleep in later to make up for lost sleep. This can confuse your body's clock and make it difficult to fall asleep again the following night.
• You are a shift worker (meaning that you work irregular hours). Non-traditional hours can confuse your body's clock, especially if you are trying to sleep during the day, or if your schedule changes periodically.

Some cases of insomnia start out with an acute episode but turn into a longer-term problem. For example, let's say a person can't sleep for a night or two after receiving bad news. In this case, if the person starts to adopt unhealthy sleep habits such as getting up in the middle of the night to work, or drinking alcohol before bed to compensate, the insomnia can continue and potentially turn into a more serious problem. Instead of passing, it can become chronic.

Once this happens, worry and thoughts such as, "I'll never sleep," become associated with bedtime, and every time the person can't sleep, it reinforces the pattern.

This is why it's important to address insomnia instead of letting it become the norm. If lifestyle and unhealthy sleep habits are the cause of insomnia, there are cognitive behavioral techniques and sleep hygiene tips that can help. If you have tried to change your sleep behaviors and it hasn't worked, it's important to take this seriously and talk to your doctor.

Insomnia & Food

Certain substances and activities, including eating patterns, can contribute to insomnia. If you can't sleep, review the following lifestyle factors to see if one or more could be affecting you:

Alcohol is a sedative. It can make you fall asleep initially, but may disrupt your sleep later in the night.

Caffeine is a stimulant. Most people understand the alerting power of caffeine and use it in the morning to help them start the day and feel productive. Caffeine in moderation is fine for most people, but excessive caffeine can cause insomnia. A 2005 National Sleep Foundation poll found that people who drank four or more cups/cans of caffeinated drinks a day were more likely than those who drank zero to one cups/cans daily to experience at least one symptom of insomnia at least a few nights each week.

Caffeine can stay in your system for as long as eight hours, so the effects are long lasting. If you have insomnia, do not consume food or drinks with caffeine too close to bedtime.

Nicotine is also a stimulant and can cause insomnia. Smoking cigarettes or tobacco products close to bedtime can make it hard to fall asleep and to sleep well through the night. Smoking is damaging to your health. If you smoke, you should stop.

Heavy meals close to bedtime can disrupt your sleep. The best practice is to eat lightly before bedtime. When you eat too much in the evening, it can cause discomfort and make it hard for your body to settle and relax. Spicy foods can also cause heartburn and interfere with your sleep.

Insomnia & The Brain 

In some cases, insomnia may be caused by certain neurotransmitters in the brain that are known to be involved with sleep and wakefulness.

There are many possible chemical interactions in the brain that could interfere with sleep and may explain why some people are biologically prone to insomnia and seem to struggle with sleep for many years without any identifiable cause—even when they follow healthy sleep advice.

Symptoms

Insomnia is difficulty falling asleep or staying asleep and is often considered chronic if it happens at least three nights per week for three months or longer.

Most of us have experienced brief periods of insomnia (also called acute insomnia). Almost everyone knows what it feels like to still be awake staring at the ceiling and wishing for sleep—this can happen when you travel and experience jet lag, or when you're anxious and overwhelmed by life circumstances.

So how do you distinguish a normal, passing sleep problem from a more serious form of insomnia that requires treatment?

Symptoms of Insomnia

According to guidelines from a physician group, people with insomnia have one or more of the following symptoms:

• Difficulty falling asleep
• Difficulty staying asleep (waking up during the night and having trouble returning to sleep)
• Waking up too early in the morning
• Unrefreshing sleep (also called "non-restorative sleep")
• Fatigue or low energy
• Cognitive impairment, such as difficulty concentrating
• Mood disturbance, such as irritability
• Behavior problems, such as feeling impulsive or aggression
• Difficulty at work or school
• Difficulty in personal relationships, including family, friends and caregivers

The duration of insomnia is important. Doctors consider insomnia chronic if it occurs at least three nights per week for three months or longer. At this point, your insomnia may be a behavioral pattern (for example, your nighttime routines do not cue your body for sleep, or your sleep schedule is out of sync with your biological clock), or it could be comorbid, meaning it is linked to another medical or psychiatric issue that needs to be addressed. Recently, researchers have begun to think about insomnia as a problem of your brain being unable to stop being awake. Your brain has a sleep cycle and a wake cycle—when one is turned on the other is turned off. Insomnia can be a problem with either part of this cycle: too much wake drive or too little sleep drive. Regardless of its cause, if insomnia has become a regular occurrence, talking to your doctor about treatment may be a good idea.

You may also want to consider whether and to what degree insomnia is affecting your life. If you feel fatigued or have low energy during the day and it gets in the way of your productivity and enjoyment of friends, family, or hobbies, that probably means you could benefit from talking to your doctor. If you've tried on your own to make adjustments to your sleep routines and it hasn't worked, you may want to enlist the help of a sleep specialist.

Diagnosis

Doctors use a number of approaches to diagnose insomnia and understand a person's unique symptoms. Some of these measures can be done at home, while others require an office visit or an appointment at a sleep clinic.

Here you'll find information on when, where, and how to seek help if you have difficulty sleeping, as well as tips for talking to your doctor and a list of questions you may want to think about before your visit to be better prepared.

There are many ways to improve your sleep that involve psychological and behavioral steps. Cognitive behavioral treatments for insomnia (CBTi), relaxation techniques, and general sleep hygiene guidelines can help many people with sleep difficulties.

Diagnosing Insomnia

There is no definitive test for insomnia. Doctors use many different tools to diagnose and measure insomnia symptoms, some of which involve asking you questions in the office, having you fill out logs and questionnaires, performing certain blood tests, or doing an overnight sleep study. All of these tests help your doctor understand your personal experience with insomnia and create the right treatment plan.

Sleep log: A sleep log is a simple diary that keeps track of details about your sleep. In a sleep log, you’ll record details like your bedtime, wake up time, how sleepy you feel at various times during the day, and more. A sleep log can also help your doctor figure out what might be causing insomnia. Here is a sample sleep log.

A sleep inventory is an extensive questionnaire that gathers information about your personal health, medical history, and sleep patterns.

Blood tests: Your doctor may perform certain blood tests to rule out medical conditions such as thyroid problems, which can disrupt sleep in some people.

Sleep study: Your doctor may suggest that you do an overnight sleep study, or polysomnography, to gather information about your nighttime sleep. In this exam, you sleep overnight in a lab set up with a comfortable bed. During the exam you will be connected to an EEG, which monitors the stages of your sleep. A sleep study also measures things like oxygen levels, body movements, and heart and breathing patterns. A sleep study is a non-invasive test.

How to Talk to Your Doctor About Insomnia 

You can talk to your doctor at one of your regular visits, or make a special appointment to go in and discuss your sleep. Many people think sleep troubles are just a normal part of life, but it's important to take sleep as seriously as you would other aspects of your health. Sleep isn't routinely addressed in annual well visits, so often patients are the ones to bring up the topic. You can ask your doctor if there is anything in your medical history that could indicate the cause of your sleep difficulty.

You may want to think about the following questions beforehand to get the most out of your conversation. You may even want to jot down notes to take with you:

• Exactly what do your sleep difficulties look like: do you have trouble falling asleep, staying asleep, or do you wake up too early? How many times a week do you have trouble sleeping like this?
• What is your sleep schedule: what time do you go to bed, wake up, and nap during the day? (even short naps count)
• Is your weekend sleep schedule different from your weekday schedule? Does your work schedule require you to adjust your sleep at all?
• What do you do when you can't sleep—get out of bed, read, watch TV, work on your laptop? Is there anything you've done in the past that has helped you sleep?
• Do you lie awake feeling anxious or worrying about responsibilities and tasks?
• What is your sleep environment like: Do you sleep alone or with a partner? Is your room dark and quiet? Is your bed comfortable? Do you have any sleep disruptions during the night, for example, young children in the house?
• How long have you had trouble sleeping? Have you had trouble sleeping on and off for as long as you can remember, or is this a new issue?
• Have you had any major changes (a move, a new job), or any stressful circumstances in your life recently (a breakup, financial troubles)?
• Do you have any medical conditions?

Treatment

You should seek help if your insomnia has become a pattern, or if you often feel fatigued or unrefreshed during the day and it interferes with your daily life. Many people have brief periods of difficulty sleeping (for example, a few days after starting a new job), but if insomnia lasts longer or has become a regular occurrence, you should ask for help.

Start by calling your primary care physician or bringing up the topic of sleep at your next well visit if you have one scheduled. If your doctor is knowledgeable about sleep disorders, he or she will guide you through the next steps, which may involve an assessment and further testing, or a referral to a sleep specialist. Your doctor may also start by giving you some basic information and resources about healthy sleep habits—these behavioral tips may help certain people with insomnia—or discussing potential medical treatment options to consider. Your doctor could refer you to a psychotherapist if your sleep struggles seem connected to anxiety, depression, or a major life adjustment.

If you don't feel satisfied after your conversation with your primary care physician, ask for a referral to a doctor who specializes in sleep medicine or consult other available resources. It's important to find a doctor who has the proper knowledge and training to treat your insomnia.

Many cities also have sleep centers and clinics (sometimes connected to a hospital) that offer assessments, testing, and treatment. An Internet search will help you locate the nearest center.

Non-Medical (Cognitive & Behavioral) Treatments for Insomnia

There are psychological and behavioral techniques that can be helpful for treating insomnia. Relaxation training, stimulus control, sleep restriction, and cognitive behavioral therapy are some examples.

Some of these techniques can be self-taught, while for others it's better to enlist the help of a therapist or sleep specialist. 

Relaxation training, or progressive muscle relaxation, teaches the person to systematically tense and relax muscles in different areas of the body. This helps to calm the body and induce sleep. Other relaxation techniques that help many people sleep involve breathing exercises, mindfulness, meditation techniques, and guided imagery. Many people listen to audio recordings to guide them in learning these techniques. They can work to help you fall asleep and also return to sleep in the middle of the night.

Stimulus control helps to build an association between the bedroom and sleep by limiting the type of activities allowed in the bedroom. An example of stimulus control is going to bed only when you are sleepy, and getting out of bed if you've been awake for 20 minutes or more. This helps to break an unhealthy association between the bedroom and wakefulness. Sleep restriction involves a strict schedule of bedtimes and wake times and limits time in bed to only when a person is sleeping.

Cognitive behavioral therapy (CBT) includes behavioral changes (such as keeping a regular bedtime and wake up time, getting out of bed after being awake for 20 minutes or so, and eliminating afternoon naps) but it adds a cognitive or "thinking" component. CBT works to challenge unhealthy beliefs and fears around sleep and teach rational, positive thinking. There is a good amount of research supporting the use of CBT for insomnia. For example, in one study, patients with insomnia attended one CBT session via the internet per week for 6 weeks. After the treatment, these people had improved sleep quality.

Medical Treatments for Insomnia

There are many different types of sleep aids for insomnia, including over-the-counter (non-prescription) and prescription medications.

Determining which medication may be right for you depends on your insomnia symptoms and many different health factors. This is why it's important to consult with a doctor before taking a sleep aid.

Major classes of prescription insomnia medications include benzodiazepine hypnotics, non-benzodiazepine hypnotics, and melatonin receptor agonists.

Alternative Medicine

There are alternative medicines that may help certain people sleep. It's important to know that these products are not required to pass through the same safety tests as medications, so their side effects and effectiveness are not as well understood.

Insomnia & You

Insomnia can have a significant impact. Some of the effects of insomnia are obvious, while others can be subtle and increase over time. Either way, it's important to address insomnia.

If you have insomnia, you may feel as though you're alone. Many people don't talk about sleep troubles—either because the problem is so long-standing it has become an accepted part of life, or because they believe they should cope with it on their own. Chances are, though, if you talk to people you know, you'll find someone else with similar sleep troubles.

As anyone who has insomnia will tell you, the very act of lying awake while the rest of the house sleeps can also feel very lonely and frustrating. Tucking into bed with your partner and then tossing and turning, staring at the ceiling or your clock, or getting back up on your own to mull around the living room can be a solitary experience. Whether you live by yourself or in a full household, insomnia can make you feel like you're the only one still awake while the rest of the world sleeps.

If you can't sleep, over time, the lack of control and unpredictability you experience can become a source of tension and worry. Not only do people with insomnia feel the effects of insufficient sleep on their mental and physical health, they also tend to feel anxiety or even dread as the evening progresses and the prospect of lying awake again looms. If this cycle sounds familiar, don't resign yourself to night after night of sub-par sleep and do not blame yourself. Know that insomnia is a sleep problem experienced by many adults and could be caused by something happening in your body that is beyond your control. There are many different treatment options for insomnia available, so talk to your doctor about what might be best for you.

Insomnia Side Effects

Insomnia is difficult in its own right, but it may also cause other issues, both psychological and physical. Many people with insomnia feel more refreshed when they get proper treatment and finally begin to sleep well again.

Chronic insomnia (difficulty sleeping for three months or longer) may also lead to changes in mood, lack of motivation and energy, irritability, and more. When you're drowsy, it may make you feel tense and preoccupied, and the worry over your inability to sleep can add to this.

For those who take care of small children or have a lot of family and work responsibilities to balance, insomnia can make these tasks feel even more overwhelming when you are tired.