Insomnia is a term used to describe several types of sleeplessness. Getting the Sleep You Need examines sleep needs, sleep stages and the effects not getting enough sleep. Because individuals require different amounts of sleep, insomnia is not defined by the number of hours of sleep a person gets or by how quickly they fall asleep, but by the quality of sleep achieved.
With insomnia, you experience a significant lack of sleep on a regular or frequent basis. Your sleeplessness may be characterized by:
Difficulty falling asleep despite being tired.
Using sleeping pills or alcohol to fall asleep.
Awakening frequently during the night or lying awake in the middle of the night.
Awakening too early in the morning and not feeling refreshed.
Daytime drowsiness, fatigue, irritability, difficulty concentrating, and impaired ability to perform normal activities.
How does insomnia affect your life?
Insomnia will negatively affect your health and well-being, particularly if it is a regular occurrence or chronic problem. If you are suffering from a lack of sleep, you may feel like you are coping fine with your fatigue, but in fact, the effects of your sleeplessness are cumulative. Without sleep, physical, mental and emotional functions are impaired, gradually at first. Because the changes are gradual, they may not register, but they are happening. You may find yourself feeling cranky and irritable all the time and find it much harder to manage the normal stresses of everyday life. Surveys report that people with severe insomnia have a quality of life that is almost as poor as people with chronic conditions such as heart failure.
If you don’t recognize and treat your insomnia, it may result in:
poor health and diminished quality of life
impaired social functioning,
increased impatience, and irritability
diminished mental alertness and memory
slower reaction times and impaired concentration
increased risk of disorders such as major depression, anxiety disorder, and substance abuse
increased likelihood of automobile, home and workplace accidents
poor job performance, missed work days, and school absences
What are the types of insomnia?
Types of insomnia are differentiated by how long insomnia lasts (duration) and whether it is caused by an underlying condition.
Transient insomnia is short-term and may last one night, a few nights, or a few weeks. Transient insomnia (sometimes called acute insomnia) is usually linked to an emotionally exciting or stressful event such as a homecoming or an argument. Sometimes a change in time zone (“jet lag”) or sleep schedule can bring on a bout of transient insomnia.
Chronic insomnia is long-term and may last a month, several months, or years. Chronic insomnia (also called constant insomnia) occurs on some or most nights, so it is considered ongoing. Chronic insomnia may be caused by either a medical problem, a psychiatric problem, a sleep disorder, or poor sleep hygiene. Self-help may solve the poor sleep habits, but professional help may be necessary for sleep disorders or for underlying medical or psychiatric problems.
Primary insomnia has no known underlying condition (insomnia is the problem). Primary insomnia is the most common type of insomnia and is usually caused by learned maladaptive sleep patterns.
Secondary insomnia is a symptom of another underlying (preexisting) condition problem that causes the insomnia. When you receive effective treatment for the underlying condition, the insomnia usually goes away.
What causes transient insomnia?
Transient insomnia lasting a few days is usually caused by:
Stress – A temporary stress (conflict or environmental change) such as starting a new job; an upcoming test at school; a family or marriage problem; financial difficulties; a death in the family; or moving to a new house or city can be a cause of insomnia. Such a stress causes a positive or negative change in mental state: the person may feel anxious, excited, worried, angry, griefstricken, euphoric, afraid, sad, hopeful, or apathetic.
Change in your environment or work schedule – Working a late or early shift or travel across time zones disrupts your body’s circadian rhythms making you unable to get to sleep when you want to .
Transient insomnia lasting more than a few days, but less than a month, is usually caused by a more enduring unsettling life event or stressor, such as a divorce, job loss, move to a new location, or death in the family.
What causes primary chronic insomnia?
Insomnia brought on by poor sleep habits, a disruptive sleep environment, or an inability to get enough sleep is called primary insomnia because insomnia is the condition to be treated. Some of the reasons for primary insomnia include (see Tips for a Good Night's Sleep for a more complete list):
Caffeine. Drinking caffeinated beverages (coffee, tea, cola) or eating chocolate in the afternoon or evening. Caffeine can delay sleep and wake you up from sleeping. More than four caffeine drinks per day interferes with sleep.
Alchohol. Drinking alcohol in the afternoon or evening. Alcohol may help you fall asleep, but it disrupts the second half of your night’s sleep.
Nicotine. Smoking cigarettes in the six hours before bedtime. Nicotine is a stimulant.
Naps. Excessive napping in the afternoon or evening. More than two naps late in the day will interfere with sleep.
Exercising within three hours of bedtime. Exercise stimulates the body by raising the heart rate and metabolism. Exercise late in the day interferes with sleep, but exercise earlier in the day helps you sleep well at night.
Excessive liquids. Liquids increase the need to get up and urinate during the night.
Mentally intense activities at bedtime (such as computer work).
Eating too much too late in the evening. Having a light snack before bedtime is OK, but eating too much may cause you to feel physically uncomfortable while lying down, making it difficult to get to sleep. Eating heavy, spicy, or high-sugar foods at night may cause indigestion
Trying too hard to fall asleep. Can occur when you worry excessively about not being able to sleep well and try too hard to fall asleep. Most people with this condition sleep better when they're away from their usual sleep environment or when they don't try to sleep, such as when they're watching TV or reading.
Noise. Too much noise in the environment (even if you fall back asleep) can prevent you from sleeping well or cause frequent awakening.
Light. Light affects your brain’s production of the hormones that regulate sleep rhythms. Too much light in the bedroom can keep your body from deep sleep.
Room temperature. You will be restless if you are too hot or cold; a comfortable room temperature is best.
Uncomfortable or too small bed.
Sleep partner or other family members. A sleep partner who snores, has sleep apnea, is very restless, gets up frequently, or has difficulty sleeping will affect your ability to sleep. Interruptions from other family members, such as a toddler or new baby, can also keep you up.
What causes secondary chronic insomnia?
Pain and depression are the two most common underlying conditions for chronic insomnia. The underlying conditions can be physical medical conditions or psychiatric conditions. This type of insomnia is often called secondary insomnia because the insomnia is a symptom of the underlying condition. Some conditions or situations that commonly lead to insomnia include:
Depression. You may either sleep too much or have trouble sleeping if you're depressed. This may be due to chemical imbalances in your brain or because worries that accompany depression may keep you from relaxing enough to fall asleep when you want to.
Pain. Medical conditions that cause pain often cause insomnia as well. For example, acid reflux (return of stomach contents into the esophagus),fibromyalgia or other chronic pain syndromes, heart disease, and arthritis, along with countless other conditions often cause sleeplessness.
Stress. Concerns about work, school, health or family can keep your mind too active, making you unable to relax. Excessive boredom, such as after retirement or during a long illness, may occur and also can create stress and keep you awake.
Anxiety. Everyday anxieties as well as severe anxiety disorders may keep your mind too alert to fall asleep.
Menopause. Between 30% and 40% of menopausal women experience insomnia; this may be due to hot flashes, night sweats, anxiety, and/or fluctuations in hormones.
Menstruation. Hormonal changes during the menstrual cycle can cause insomnia; sleep tends to improve mid-cycle with ovulation.
Growing older. Changes associated with aging include changes in sleep patterns (more time in Stages 1 & 2, less time in stages 3 & 4); becoming less physically and socially active; hormonal changes, and health problems which cause more chronic pain.
Long-term use of sleep medications. Sleeping pills often become less effective over time. If a person suddenly stops taking or becomes tolerant of a long-term prescription medication, insomnia may result. If you need sleep medications for longer than a few weeks, take them no more than two to four times a week, so they don't become habit-forming.
Medication side effects. Prescription drugs, including some antidepressant, high blood pressure and corticosteroid medications, can cause sleeping difficulties as a side effect . Many over-the-counter (OTC) medications, including some pain medication combinations, decongestants and weight-loss products, contain caffeine and other stimulants. Antihistamines may initially make you groggy, but they can worsen urinary problems, causing you to get up more during the night.
Caffeine, alcohol, recreational drugs and smoking. Consuming excessive amounts of caffeine, alcohol, recreational drugs, smoking can cause restlessness and smoking cessation may also result in temporary insomnia. If you use alcohol to help you fall asleep, you may have insomnia when you do not use it. Alcohol in any amount negatively affects sleep quality and duration.
Other medical conditions. Other causes of secondary insomnia include sleep apnea, restless legs syndrome, circadian rhythm disorder, arthritis, kidney disease, heart failure, asthma, sleep apnea, narcolepsy, restless legs syndrome, Parkinson's disease and hyperthyroidism.
How do doctors diagnose insomnia?
Talking with your doctor about insomnia or sleeplessness can be frustrating. The numerous possible reasons for insomnia might make it difficult for your doctor to quickly identify the cause of your sleep problems, and doctors don’t agree on the best method for diagnosing insomnia. Diagnosing insomnia is subjective, and many people who believe they have insomnia have the same sleep behaviors as people who don’t think they have insomnia. For example, a person may think they are constantly awake when in fact they are awakening briefly and falling back asleep throughout the night. However, if you feel that you have insomnia and are very tired on a regular basis, it is important to talk with your doctor about your sleep troubles. Finding the cause of sleeplessness is the first step to solving the problem. Two signs that generally call for sleep help are:
Excessive daytime tiredness
Memory and concentration trouble
Your doctor will want to rule out possible medical conditions and may want you to try making behavioral and environmental changes as first steps to helping you sleep better.
How do I prepare to talk to my doctor about insomnia?
Before talking to your doctor, prepare yourself with as much information about your sleep habits as possible. Sleep questionnaires and sleep diaries can be quite helpful – see below for more information on both. If you have a sleep partner, enlist his or her help in finding out about your sleep patterns. If your insomnia is severe, your doctor might recommend a stay at a sleep center, where you can be monitored while you sleep.
Sleep Questionnaires
A sleep questionnaire might help you gather information helpful for a doctor. Sleep questionnaires may vary slightly, but all try to assess your sleep problem, sleep habits, sleep environment, eating and drinking habits, current stress level and physical ailments. Sample questions, provided by University of Maryland Medical Center are:
How would the sleep problem be described?
How long has the sleep problem been experienced?
How long does it take to fall asleep?
How many times a week does it occur?
How restful is sleep?
Does the difficulty lie in getting to sleep or in waking up early?
What is the sleep environment like (Noisy? Not dark enough?)?
How does insomnia affect daytime functioning?
What medications are being taken (including the use of self-medications for insomnia, such as herbs, alcohol, and over-the-counter or prescription drugs)?
Is the patient taking or withdrawing from stimulants, such as coffee or tobacco?
How much alcohol is consumed per day?
What stresses or emotional factors may be present?
Has the patient experienced any significant life changes?
Does the patient snore or gasp during sleep (an indication of sleep apnea)?
Does the patient have leg problems (cramps, twitching, crawling feelings)?
If there is a bed partner, is his or her behavior distressing or disturbing?
Is the patient a shift worker?
Sleep Diary
Keeping a detailed sleep history or sleep diary can help you (or a physician) identify factors related to insomnia and whether other disorders are the cause of the insomnia. A sleep diary should record all sleep-related information, including:
Time you went to bed and woke up; total sleep hours and quality of sleep;
Times that you were awake during the night and what you did (e.g. stayed in bed with eyes closed or got up, had a glass of milk and meditated);
Types and amount of food, liquids, caffeine or alcohol you consumed and times of consumption;
Feelings and moods - happiness, sadness, stress, anxiety
Drugs or medications taken, amounts taken and times of consumption
A sleep diary is also a good place to record answers to sleep questionnaire questions (see above).
A sleep partner should add observations to your sleep diary as well. Keeping a sleep diary for at least two weeks may uncover some sleep patterns of which you were unaware. For example, a sleep diary might reveal that you don’t sleep well if you have had more than two alcoholic drinks before bedtime or that you more trouble falling asleep on days when you haven’t exercised. The details can be important, and keeping a sleep diary might reveal that your pre-bedtime behavior is thwarting your chance for a good night’s sleep.
For sample sleep diaries see Helpguide’s Sleep Diary or the American Academy of Family Physicians' article Insomnia: Assessment and Management in Primary Care (scroll down in article for the sleep diary).
Measuring Sleepiness
Measuring sleepiness helps indicate the severity of insomnia, but sleepiness is subjective and difficult for a doctor to assess based just on conversation with a patient. Two tools used to measure sleepiness are described below.
The Epworth Sleepiness Scale rates sleepiness during different everyday situations to determine whether a person is excessively sleepy or just normally sleepy. Interactive on-line version provided by Drug Digest. If score is 10 or more (UMMC recommends 9 or more) patient should seek medical advice
Multiple Sleep Latency Test. After some sleep disorders have been ruled out, a doctor might suggest a multiple sleep latency test (MSLT). For the MSLT, you take four or five scheduled naps two hours apart during the day, while a machine measures the time it takes to fall asleep. People with healthy sleep habits generally fall asleep within 10-20 minutes, and the test helps pinpoint changes in sleepiness in people with insomnia, but it does not allow for differences due to mental difficulties.
How does a sleep center diagnose insomnia?
If your doctor suspects a sleep disorder or is unable to determine a cause for your insomnia, a stay at a sleep center might be recommended. At a sleep center, a team of sleep specialists will be able to use the latest tools and technology to monitor you while you sleep. Then, they can provide both physical and psychological evaluations. Sleep centers are accredited by the American Academy of Sleep Medicine, and you should investigate a center to make sure they are accredited and that they provide full sleep studies before making an appointment. See the American Academy of Sleep Medicine’s Sleep Center Locator for more information about finding a sleep center near you.
The University of Maryland Medical Center provides a list of signs that may indicate a need for a sleep center:
Insomnia due to psychological disorders.
Sleeping problems due to substance abuse.
Snoring and sudden awakening with gasping for breath (possible sleep apnea).
Severe restless legs syndrome.
Persistent daytime sleepiness.
Sudden episodes of falling asleep during the day (possible narcolepsy).
Some of the tools used by sleep centers are:
Polysomnography uses an instrument to electronically monitor the patient during sleep. It is not used for routine evaluations of insomnia, but may be used to rule out other sleep disorders. The polysomnograph monitors brain waves, body movements, breathing and heartbeat during sleep.
Actigraphy uses an activity monitor, called an actigraph to record body movements during wakefulness and sleep. It can be worn night and day at home, so the conditions are more natural than tests done in a laboratory. It can also keep a record over several nights rather than a single session. The actigraph cannot distinguish whether the patient is awake or asleep.
Part I of this eBook is filled with practical tips and suggestions for addressing general sleep issues including insomnia and snoring. Part II covers other sleep disorders including sleep apnea, RLS and narcolepsy. See eBook contents below.
References and resources for insomnia
University of Maryland Medical Center provides a comprehensive series of easy-to-read articles:
What Is Insomnia? – Outlines the duration and forms of insomnia along with a section on healthy sleep.
What Are The Causes Of Short-Term Or Transient Insomnia? – Discusses life changes, stress, hormonal fluctuations, jet lag, environmental causes, nicotine, caffeine, partner’s sleep habits, and medications.
What Causes Chronic Insomnia? – Addresses causes including medical conditions, emotional disorders, alcohol use, hormonal abnormalities and genetic factors.
Who Has Insomnia? – Includes risk factors.
How Serious Is Insomnia? – Includes effects on mood and quality of life.
How Is Insomnia Diagnosed? – Includes sleep questionnaires and measuring sleepiness
What Are Behavioral And Other Non-Drug Treatments For Insomnia? – Covers seven types of behavior methods listed in order of effectiveness. Stimulus control is ranked highest.
Insomnia – Complementary Medicine – Covers nutrition and dietary supplements; herbs; homeopathy; acupuncture; chiropractic; massage and physical therapy; mind/body medicine and traditional chinese medicine.
What Are Drug Treatments For Insomnia? – Provides general guidelines; common non-prescription drugs; natural remedies; hypnotics: benzodiazepines; and other prescription drugs. Includes treatments for specific groups of people.
Where Else Can Help For Insomnia Be Obtained? – Includes a dozen recommended sites.
Insomnia – Easy-to-read article addresses signs and symptoms, common causes, screening and diagnosis, and treatment. (MayoClinic.org)
Causes of Insomnia – Addresses psychological, lifestyle and environmental factors (American Insomnia Association)
Sleep Disorders in Children and Teens – Includes illustrative case reports aimed at “Helping patients and their families get some rest.” (Postgraduate Medicine Online)
Common Sleep Problems – Focuses on several sleep problems, written for teens. (Teens Health)