Insomnia is commonly referred to as a difficulty initiating or maintaining sleep or as a non-refreshing sleep. According to The International Classification of Sleep Disorders Diagnostic and Coding Manual (2005), insomnia is defined as “a repeated difficulty with sleep initiation, duration, consolidation, or quality”. Although adequate time and opportunity for sleep are granted, insomnia often results in some form of daytime impairment. Insomnia is not necessarily a disease per se, but often manifests as a symptom of an underlying condition.
Short-term or transient insomnia may occur following a stressful event (loss of a loved one, job, relationship disagreement), a life-changing event (a recent move) or an anticipated event (a wedding or an exam). The patient may not be able to relax, have disturbed sleep and in most cases, can pinpoint the reason or original trigger for the insomnia. Other factors that may contribute to short-term or transient insomnia include jet lag, alternating circadian rhythms due to shift-work as well as side effects from over-the-counter medications containing caffeine or other wake-promoting substances. The stress of experiencing transient insomnia can perpetuate into a chronic “psychophysiological” or “conditioned” insomnia if the individual begins to associate their bed as a place of frustration, dread or struggle instead of a place of rest and relaxation.
Chronic insomnia arises when the patient has trouble falling asleep, maintaining sleep or experience non-restorative sleep for at least a month in duration. Normal functioning is impaired due to sleep loss. Chronic-intermittent insomnia takes place when an alternating pattern develops between several nights of insomnia and a few nights of good sleep. Causes of chronic insomnia include, among others, medical conditions, poor sleep hygiene, limb movements during sleep and sleep-relating breathing disorders, hormonal changes, circadian rhythm disorders, and inconsistent sleep-wake schedule.
Symptoms
You may have insomnia if
- You are unable to get the proper amount of sleep to feel refreshed and rested
- You can’t sleep despite being tired
- You experience restless sleep that leaves you fatigued upon awakening
Consequently, you may feel tired, irritable, experience a general malaise, and have trouble concentrating. It may affect your social and work life and impact your overall quality of life. Some individuals may complain of muscle tension, gastrointestinal symptoms and headaches. Children may experience poor school performance.
Insomnia can be acute (lasting just one to several nights) or chronic (lasting months to several years).
When should you suspect insomnia?
If you answer yes to at least 3 of the following questions, you may have clinically siginificant insomnia. Consult a qualified sleep medicine specialist to get the proper evaluation and best treatment plan.
- Do you have trouble falling or staying asleep?
- Do you wake up frequently during the night?
- Do you wake up too early in the morning?
- Do you feel unrefreshed when you wake up in the morning?
- Do you feel sleepy during the day?
- Do you experience at least one of the following symptoms:
- Irritability / Mood changes
- Decreased concentration
- Lack of motivation
- Make errors while driving or working
- Decreased energy
- Digestive complaints
- Disturbed, frustrated and worried about sleeping properly
Causes
Insomnia may be due to pain, medical illnesses, depression or mental disorders, other sleep disorders, tobacco use, exposure to or use of certain substances and medications, as well as stress and worry. Insomnia may be worse if you have poor sleep hygiene in addition to feeling anxious about falling or staying asleep.
Characteristics
According to the National Center for Sleep Disorders Research at the National Institutes of Health, insomnia of any degree affects about 30-40% of the adult population in a given year, with about 10-15% reporting chronic insomnia. It is more common in women than men, especially during menopause. This trend reverses later in life, as older men seem more susceptible to insomnia than women. Complaints of insomnia increase with age when sleep has a tendency to become more easily fragmented.
Consequences
You should correct any inappropriate sleep habits and patterns that may lead to insomnia, such as alcohol consumption prior to bedtime or inadequate sleep hygiene. You may want to talk about your insomnia with your primary care physician and seek help from a qualified and accredited sleep medicine specialist.
Because insomnia is often a symptom of an underlying condition, it is best to seek a qualified sleep medicine center to adequately rule out other medical disorders contributing to the insomnia and get to the root of the problem, thus maximizing the likelihood for successful treatment. Your sleep medicine physician will investigate all potentials causes of the insomnia through a comprehensive and thorough interview and physical examination. You may be asked to keep a sleep diary for several weeks to record relevant sleep information and other health-related issues. Upon reviewing the sleep diary results or feedback obtained during the consultation, your sleep medicine physician may recommend an overnight sleep study (polysomnography) to rule out any other potential sleep disorders contributing to your insomnia.
Diagnosis
Behavioral therapies
Behavioral treatment is often recommended to retrain an individual’s behaviors or perceptions towards maximizing sleep quality and establishing a conducive sleep environment or positive sleep patterns. Behavioral therapies are often used as the first step in a treatment plan. There are numerous behavioral techniques available to treat insomnia. Taken together, some of these techniques comprise what is referred to as "cognitive behavioral therapy." It is important to note that cognitive behavioral therapy (CBT) has been shown to out perform sedative-hypnotic medications for the long-term treatment of insomnia.
Behavioral therapies include:
- Establishing good sleep hygiene to promote healthy sleep habits. Maintaining a strict sleep-wake schedule throughout weekdays and weekends is essential in establishing a healthy sleep-wake schedule. See sleep hygiene guidelines for more details.
- Sleep restriction therapy. Some individuals have a tendency to spend too much time in bed, often to make up for a "bad night of sleep." Spending too much time in bed will typically exacerbate the difficulty consolidating sleep at night and lead to a worsening of the insomnia. Sleep restriction therapy restricts the time spent in bed to approximate the actual total sleep need, leading to a short-term sleep deprivation, but helping "train the brain" to consolidate sleep at night.
- Stimulus control therapy. Many patients develop "bad habits" when faced with a chronic insomnia, such as frequently watching the clock and "counting down" the time remaining before needing to start their day, or spending extended periods of time in bed without sleeping, or worrying about the consequences of having a bad night of sleep. Stimulus control therapy is employed to break negative associations of the bed as a place of frustration. As an important technique of stimulus control therapy, patients are instructed to not watch the clock and to even remove the clock from the bedroom. The insomnia patient should not stay longer than 20-30 minutes in bed without sleeping. Getting out of bed when not able to sleep, helps break the association of the bed as a place of frustration or dread. Finally, patients should not "catastrophize" when faced with a "bad night," but instead should try to view a bad night in a positive light in the sense that the sleep deprivation experienced from a bad night will help consolidate sleep the following night. Stimulus control therapy is particularly useful for patients with chronic "psychophysiologic," or conditioned, insomnia.
- Relaxation techniques such as yoga, meditation, and guided imagery.
- Regular exercise conducted at least three hours before bedtime.
- Light therapy is sometimes utilized to shift an individual’s circadian rhythm to a desired sleep-wake schedule. The timing of light pulses to shift the circadian rhythm needs to be specifically tailored to each patient’s individual needs.
Treatment
The use of medications to treat insomnia should be tailored for the individual. As much as possible, medications should be directed to the underlying cause of the insomnia. For example, if depression or anxiety is the underlying cause of the insomnia, an antidepressant may be helpful. On the other hand, if heartburn or acid reflux disrupts sleep, medications to treat acid reflux may be indicated. The treatment of choice will depend on your specific health-related issues.
It is important to note that many medications can worsen or cause insomnia, such as antidepressants, stimulants, beta blockers or other heart medications, decongestants, etc. If your insomnia is caused or exacerbated by a medication you may benefit from switching to a different medication.
If behavioral therapy and the treatment of other underlying medical conditions are not adequate to improve the insomnia, a medication such as a sedative-hypnotic may be prescribed. Such medications can be helpful, but should be limited to specific cases, and patients need to be followed by their physician. Some of the side effects include a potential risk for drug tolerance and dependence and other health risks when combined with alcohol or in patients with pre-existing obstructive sleep apnea.
For More Information
For more information about insomnia, visit the American Academy of Sleep Medicine at http://www.sleepeducation.com and the National Sleep Foundation at http://www.sleepfoundation.org
