Almost everybody, at some point in their lives, has had difficulty falling asleep. Each night, millions of Americans have trouble falling asleep. While most of these cases are due to an occasional night of poor sleep that can be remedied the following night, patients suffering from insomnia experience sleep difficulties for months to years. In fact, nearly one in three people suffer from some form of insomnia during their lifetime.
15-20% of Americans have short-term insomnia lasting less than three months, while 10% of the US population suffers from chronic insomnia – a condition that lasts at least three times per week for at least a month.
Symptoms and consequences of insomnia can produce negative effects on a person’s health and quality of life. Insomnia can be assessed and treated with lifestyle changes or certain medications. Consider speaking with a medical provider if you are experiencing recurring sleep difficulties.
What is Insomnia?
Insomnia is a sleep disorder that makes it difficult for patients to fall asleep, stay asleep, or both, despite the opportunity to get a full night of sleep each evening.
Initial insomnia is difficulty falling asleep. Middle insomnia describes the inability or trouble patients have remaining asleep throughout the night. Terminal insomnia is waking up too early. Insomnia may also be characterized by sleep that is un-restorative or unrefreshing.
The effects of insomnia extend from the night and throughout the day. People suffering from insomnia often repeatedly wake feeling unrefreshed, groggy, tired, irritable, and unwell. Difficulties sleeping can lead to decreased energy throughout the day, affecting a patient’s ability to perform everyday functions and attend to daily responsibilities. Tired persons may have impaired decision-making and reduced alertness, which may lead to accidents, impaired work performance, or negatively affect relationships and daily interactions.
While the average amount of sleep per night varies with each person, most adults typically need between 7 to 8 hours of restful, uninterrupted sleep each night. Although a small population of people can be classified as “short sleepers” – able to get five hours of sleep or less and function normally – the typical person needs a longer period of rest for a full night of restorative sleep.
While insomnia can affect anybody, it is more common in older adults (typically 60 years of age or older,) women, people who travel frequently, shift workers with frequent shift changes (often overnight shifts,) people suffering from stress, patients with certain medical conditions, and patients with mental health conditions (such as depression.)
Patients suffering from insomnia are also at a higher risk of developing chronic diseases and having a poorly functioning immune system. Those suffering from insomnia may also develop obesity, anxiety, depression, become irritable, experience concentration or memory difficulties, and have slower reaction times.
Insomnia can be classified as primary or secondary. Primary insomnia is insomnia that is not directly related to another health condition, medical or psychiatric problem, or environmental cause. Secondary insomnia is insomnia that is related to, or a result of another problem, such as a health condition, medication use, or substance use.
Insomnia can vary from patient to patient. Some people only experience short-term insomnia, which may last only days or weeks. Short-term insomnia can be broken down into transient insomnia – which lasts from a few days to weeks, and acute insomnia – which persists for several weeks. Long-term, or chronic insomnia, involves a person experiencing insomnia at least three times per week for at least one month. Some patients experience insomnia that is irregular and infrequent, it may come and go with periods of restful nights of sleep in between (intermittent insomnia.)
What Causes Insomnia?
Insomnia may occur due to a variety of causes. Several common causes, or underlying issues with side effects of insomnia, include:
- Significant life event – death of a friend or loved one, divorce, loss of job, job change, moving
- Anxiety and excessive worrying
- Exhilaration, excitement
- Bipolar disorder
- Post-traumatic stress disorder (PTSD)
- Medications – antidepressants, heart medications, blood pressure medications, allergy medications, stimulants, corticosteroids, pain medications, weight-loss medications, decongestants
- Excessive sleep/napping during the day
- Withdrawal of medications
- Starting a new medication
- Poor sleep habits – such as going to bed too late each night, irregular sleep schedule (shift worker disorder)
- Eating late at night
- Medical condition – arthritis, cancer, heart failure, lung disease, GERD, overactive thyroid, Parkinson’s disease, Alzheimer’s disease, restless leg syndrome, COPD, chronic fatigue syndrome, brain tumors, stroke, congestive heart failure
- Estrogen level changes – menstruation, menopause, hot flashes
- Sleeping next to a snoring person
- Chronic pain
- Environmental factors – noise, light, extreme heat, extreme cold, high altitudes
- Media technology (TV, computer, video games, cell phones) in the bedroom
- Physical discomfort
Acute insomnia is caused more often by environmental factors, significant life events, short-term medications, or changes in sleep schedule.
Chronic insomnia may be caused by underlying depression, chronic stress, or a long-term condition.
Insomnia becomes more common as people age. This may be due to changes in natural circadian rhythms (sleep patterns,) a change in health, consumption of more medications, or a change in activity levels.
Signs and Symptoms of Insomnia
Insomnia is characterized by lack of, or difficulty with, sleeping during the night. Common symptoms include:
- Difficulty falling asleep
- Difficulty remaining asleep (waking up during the night)
- Waking up too early
- Nonrestorative sleep – feeling unrested and unrefreshed after a night of sleep
- Fatigue during the day
- Irritability, moodiness
- Lack of energy
- Cognitive impairment – difficulty paying attention, concentrating, focusing or remembering
- Increased number of accidents or errors
- Tension headaches
- Stomach discomfort
- Constant worrying, confusion or frustration about sleeping
Prevention of Insomnia
Maintaining a healthy and active lifestyle – including healthy sleep behaviors – can reduce a person’s chance of suffering from insomnia.
Healthy sleep habits include:
- Going to bed at the same time each night
- Waking up at the same time each morning
- Avoiding caffeine in the afternoon
- Avoiding excess alcohol – although alcohol may make people fall asleep easier, it induces a lighter than normal sleep, making it more likely that patients wake up in the middle of the night
- Having a regular exercise routine
- Limiting daytime naps – try to keep naps less than 30 minutes, and before 3pm
- Trying to relax before going to sleep – reading, meditation or sitting quietly can help relax the mind
- Avoiding heavy meals prior to bedtime – heavy food or drink may upset your stomach, leading to digestion problems during the night
- Making your bedroom “sleep-friendly” – dark and quiet; reducing bright lights, limiting TV and other electronics, setting the temperature to a comfortable level
- Many people find it helpful to turn off cell phone notifications, or even keep cell phones outside of the bedroom at night, to avoid distractions that may cause them to wake up in the middle of the evening.
Treatment of Insomnia
When lifestyle changes and attempts at healthy sleeping habits do not resolve sleep issues and insomnia, certain therapies and medications can be used in an effort to regain regular sleep patterns.
Many patients with insomnia find treatment through Cognitive Behavioral Therapy for Insomnia (CBT-I.) CBT-I is the recommended first line of treatment for patients suffering from insomnia. With CBT-I, patients work with sleep specialists and learn new strategies and behaviors that can help patients sleep better. CBT-I also addresses behaviors and thoughts that may be impeding patients from achieving a good night of sleep. CBT-I techniques includes strategies such as relaxation, stress reduction, and management of a healthy sleep schedule. Most successful CBT treatments require weekly sessions for at least 2 to 3 months.
Other behavioral therapies offered for insomnia relief include partial sleep restriction, light therapy, stimulus control, and remaining passively awake as patients try to fall into a relaxed sleep. Another behavior therapy technique is reconditioning, which involves training patients to associate the bed with sleep, and encouraging people to use the bed for sleep and sex only.
Certain medications can help patients who are suffering from insomnia. Many common over-the-counter sleep aids contain antihistamines, which help patients become drowsy. Antihistamines have several side effects of their own, including decreased quality of sleep, daytime sleepiness, dizziness, dry mouth, confusion, and urinary problems.
Other over-the-counter and alternative insomnia products include melatonin, L-tryptophan supplement, valerian teas and extracts. Many supplements and “natural” products are not regulated by the FDA, and their efficacy may not be scientifically proven, although some patients find insomnia relief through their use.
Some patients have also found relief through acupuncture, yoga, and meditation.
A medical provider can also prescribe certain medications to help patients fall asleep. The Centers for Disease Control and Prevention estimates that about 4% of Americans use prescription sleep medications each month. Approved medications that treat insomnia are called hypnotics. Most prescription sleeping medications are only recommended for use over a period of a few weeks, but there are a few long-term use sleep aid medications. As with any other medication, it is important to be aware of the risks and side effects related to a prescribed drug, so that it can be used safely and properly. Some medications that a medical provider may prescribe for insomnia include:
- Zolpidem (Ambien)
- Eszopiclone (Lunesta)
- Zaleplon (Sonata)
- Ramelteon (Rozerem)
When insomnia is caused by an underlying condition, a medical provider will work with you to try to treat the underlying condition, or refer you to a specialist.
When Should I Call a Doctor?
If insomnia makes it difficult for you to function during the day, consider speaking with a medical provider. Your doctor can work with you to determine the cause of your sleep problem, and can help you develop a healthy and safe sleep plan.
Some patients are referred to a sleep specialist or sleep center for further testing and assessment of insomnia.
With the proper medical help, lifestyle changes, and other proven interventions, insomnia can be managed, or even cured.
Even though primary insomnia may not be curable, secondary insomnia could be cured if the underlying condition is cured or treated.
Please note: MeMD Providers cannot prescribe any sleep aids listed on the DEA Controlled Substances Schedule.