Insomnia

Insomnia is a sleep disorder in which a person has difficulty falling or staying asleep. As many as two-thirds of adults live with the symptoms of insomnia.

Untreated insomnia can lead to unwanted consequences such as fatigue, poor performance at work or school, and a lower quality of life. Fortunately, many people with insomnia see improvements in their symptoms with appropriate lifestyle changes and treatment.

To help illuminate this common condition, we break down the symptoms and causes of insomnia and discuss some of its treatments. We also explore strategies for preventing insomnia and improving the length and quality of your sleep.

Insomnia is characterized by an inability to fall asleep, stay asleep, or get quality sleep, even when someone has the chance for sufficient rest. Insomnia can also cause issues during the day like daytime sleepiness, poor concentration, and changes in mood.

While anyone with trouble sleeping may describe themselves as having insomnia, temporary or periodic sleep troubles are different from an insomnia disorder. A person may be diagnosed with an insomnia disorder if they have persistent sleep issues and daytime symptoms despite adequate time and opportunity for sleep.

Insomnia can be diagnosed as short-term or chronic, depending on how long the symptoms go on.

• Short-Term Insomnia: Also called acute insomnia, short-term insomnia involves symptoms that last for fewer than three months. Around 15% to 20% of adults experience some degree of short-term insomnia.
• Chronic Insomnia: Insomnia is classified as chronic when symptoms are present three or more times a week for three months or longer. Chronic insomnia can last for years, with symptoms increasing and decreasing periodically. An estimated 10% to 15% of adults experience chronic insomnia.

Insomnia may also be described by a person’s specific symptoms.

• Sleep Onset Insomnia: Sleep onset insomnia refers to having difficulty falling asleep. The average adult takes about 10 to 20 minutes to fall asleep, while a person with sleep onset insomnia may take 30 minutes or more.
• Sleep Maintenance Insomnia: People with sleep maintenance insomnia may spend over 30 minutes awake at night because they can’t fall back to sleep when their sleep is interrupted. By contrast, the average sleeper spends fewer than 30 minutes awake during the night.
• Mixed Insomnia: People can also have a combination of both sleep onset insomnia and sleep maintenance insomnia. Health care professionals may refer to this as mixed insomnia.
• Paradoxical Insomnia: A person with this diagnosis believes that they have insomnia despite a sleep study showing that they spend enough time sleeping after all. People with paradoxical insomnia often think they spend a lot of time awake at night and may have daytime insomnia symptoms despite getting plenty of rest.

To be diagnosed with insomnia, a person must have both nighttime and daytime symptoms. Nighttime symptoms of insomnia include:

• Difficulty falling asleep
• Difficulty staying asleep through the night
• Waking up too early

In children, nighttime symptoms may also include resisting sleep and having trouble sleeping without a caregiver’s help.

Daytime symptoms of insomnia include: 

• Daytime sleepiness
• Fatigue
• Diminished motivation
• Irritability or other mood changes
• Difficulty concentrating, remembering, or paying attention
• Worrying about sleep loss

Children with insomnia may also exhibit behavioral issues at home or in school, as well as offer resistance when caregivers try to set behavioral limits.

Doctors can’t always tell why someone develops insomnia. A person’s risk of insomnia can be influenced by multiple factors such as stress, daily activities, and coexisting mental and physical health conditions.

Stress and Daytime Habits

Stress at work, at school, or in relationships is a common cause of short-term insomnia. Stress triggers changes in the body, including elevating the heart rate while affecting the release of certain hormones. Together, these changes make a person more aware of their surroundings and less able to fall asleep.

Daytime habits can also contribute to insomnia. Exercising, drinking alcohol or caffeinated beverages, or smoking near bedtime can make it harder to get quality sleep, as can keeping an inconsistent sleep schedule.

Mental Health Conditions

Having a mental health condition increases a person’s chances of developing insomnia. In fact, the majority of people living with a mental health condition also experience insomnia at some point.

Mental health conditions associated with insomnia include depression, anxiety, post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), and substance abuse disorders.

Mental health conditions and insomnia affect each other, and it’s not always clear which came first. Because of this complex relationship, treatment for insomnia often targets both sleep-related symptoms and coexisting conditions that may be influencing sleep difficulties.

Medical Conditions

Insomnia and other sleep issues are often related to underlying medical conditions. For instance, insomnia affects up to half of all people with diabetes and between 30% to 50% of those who have cancer. Additionally, sleep issues like insomnia affect more than 80% of people with Parkinson’s disease.

For people with these and other medical conditions, insomnia often results from the condition’s symptoms, such as pain. As many as 75% of people with chronic pain have insomnia. But insomnia may also stem from the side effects of treatment or the emotional impact of being diagnosed with a serious disease.

Medications and other substances that may contribute to insomnia include antidepressants, alcohol, tobacco, stimulants like caffeine, and beta blockers, which are a class of drugs often used to treat heart disease. Withdrawal from medications such as sedatives can also trigger insomnia.

Other Sleep Disorders

In some cases, insomnia is related to other sleep disorders. Notably, both restless legs syndrome and sleep apnea produce insomnia symptoms in many people diagnosed with these conditions.

Circadian rhythm sleep-wake disorders may also be responsible for insomnia. These sleep disorders are caused by a misalignment between a person’s environment and their body’s internal clock. For example, traveling across several time zones can also disrupt the body’s internal clock, leading to jet lag and insomnia.

Since many sleep disorders can cause insomnia symptoms, doctors may not diagnose a person with insomnia disorder unless there is evidence suggesting that two sleep disorders are separate.

Anyone can develop insomnia. However, there are several groups that have a higher risk for this disorder.

Children and Teens

Research shows that insomnia symptoms are common among children and teens.

• Preschool-Aged Children: As many as 20% of preschoolers and early school-aged children have symptoms of insomnia. Children with other medical conditions have the greatest risk of developing insomnia.
• School-Aged Children: Estimates of insomnia symptoms in school-aged children range from 20% to 40%. Difficulty falling asleep is the most frequent symptom of insomnia in this age group.
• Teenagers: An estimated 11% of teenagers experience insomnia. Teens who have autism, anxiety, depression, or ADHD also have the highest risk of sleep problems.

Shift Workers

A shift worker is someone who regularly works before 7 a.m. or after 6 p.m. Trying to sleep during the day and work at night can put a person’s internal clock out of alignment with their environment, leading to insomnia among other consequences.

Shift workers are twice as likely to have insomnia as people who work during the day. Additionally, shift workers frequently sleep fewer than seven hours each day, which increases their risk of workplace accidents, obesity, and long-term health complications.

People Who Are Pregnant

Sleep issues are common among people who are pregnant. An estimated 38% of pregnant people experience symptoms of insomnia and the likelihood of insomnia increases in each trimester of pregnancy. Causes of insomnia in pregnant people include:

• Nausea
• Nighttime urination
• Backache or leg cramps
• Fetal movements
• Heartburn or indigestion
• Physical discomfort
• Difficulty finding a comfortable sleep position

People Who Menstruate

Sleep quality can be affected by both the menstrual cycle and menopause. Each stage of the menstrual cycle is marked by a fluctuation in certain hormones, leading to a number of physical and emotional symptoms, including poor sleep. These symptoms can emerge days or hours before menstruation begins and vary in duration. 

Period-related discomfort and pain can exacerbate insomnia or insufficient sleep. Cramps, bloating, headaches, backaches, and other related symptoms can make it difficult to fall and stay asleep. Research also shows that those with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) may experience a decreased amount of REM sleep during menstruation, which can lead to excessive sleepiness during waking hours. 

Menopause also has the potential to influence sleep architecture. A number of common menopause symptoms — including hot flashes — can occur at night, and may lead to fragmented sleep and premature wakening. Perimenopausal women are also at a heightened risk of developing sleep related breathing disorders, including obstructive sleep apnea (OSA).

Older Adults

Insomnia is one of the most common sleep issues in older adults. It’s estimated that between 12% and 20% of people over 60 have an insomnia disorder, while 30% to 48% have occasional symptoms of insomnia.

Sleep issues in older adults can have a variety of causes, including medications and conditions that become more common as people get older. These include chronic pain, nighttime urination, mental and emotional health conditions, and night sweats.

If left untreated, insomnia can lead to a number of consequences that can interfere with your health and day-to-day life.

• Daytime Fatigue: People with insomnia may have low energy and feel overly tired during the day.
• Unwanted Changes in Mood: Insomnia may make a person irritable or anxious and can lower their sex drive.
• Reduced Judgment and Performance: A lack of sleep impacts thinking, reaction times, and decision making. It can also lead to difficulties with memory and problem solving.
• Increased Risk of Accidents: People who are sleep deprived have a greater risk of car accidents. In fact, the risk of fatal car crashes is two to three times higher in people with chronic insomnia.
• Elevated Risk of Health Problems: Insomnia increases a person’s risk for cardiovascular conditions including high blood pressure, heart disease, and heart attack. People with insomnia are also at greater risk for diabetes, obesity, and asthma.

Treatment for insomnia typically begins with an evaluation of coexisting health conditions and other factors that may cause sleep problems. Treating these factors at the same time as addressing sleep issues may offer the best chance of success.

Treatment for short-term insomnia regularly involves education about sleep health, as well as identifying any causes of stress. In some cases, doctors may treat short-term insomnia with medication to prevent daytime sleepiness or relieve anxiety about sleep.

The preferred treatment for chronic insomnia is cognitive behavioral therapy for insomnia (CBT-I). CBT-I involves sleep education along with strategies to combat the mental and behavioral causes of sleep difficulties. Strategies include reducing the amount of time spent awake in bed and developing healthy sleep habits.

Relaxation practices are another important aspect of CBT-I and have been shown to improve insomnia symptoms. Some example techniques are progressive muscle relaxation, deep breathing, and meditation.

Doctors may recommend medications or sleep aids if chronic insomnia symptoms do not improve with CBT-I. People with insomnia should consult with their health care providers before beginning any medications or sleep aids.

When to Talk to Your Doctor About Insomnia

You may want to consult your doctor if you have symptoms such as difficulty sleeping or daytime fatigue. A doctor can evaluate your symptoms, diagnose the cause of your sleep problems, and create a personalized treatment plan.

Your doctor may ask you to keep a sleep diary for around a week. A sleep diary is a record of your specific sleep problems, the times when you fall asleep and wake up, and other observations related to your sleep habits.

A blood test is not usually needed to confirm an insomnia diagnosis. However, your doctor may recommend laboratory tests if they suspect that underlying health issues are to blame for your symptoms.

Typically, a sleep study is not required either. But a sleep study can help doctors detect other sleep disorders that could contribute to your insomnia, such as obstructive sleep apnea.

Preventing insomnia involves cultivating healthy sleep habits. Making several lifestyle changes can improve your sleep hygiene. 

• Exercise Daily: Getting at least 30 minutes of exercise each day can make it easier to fall asleep at night. But avoid exercising too close to bedtime, which can keep you awake.
• Avoid Napping Late in the Day: Naps can make it harder to fall asleep at night if taken too late in the day. If you need a daytime nap, try to keep it under 30 minutes and take it at least eight hours before bedtime.
• Create a Quiet, Dark, and Comfortable Sleep Environment: Making a comfortable sleep environment can help promote better sleep. Accessories such as white noise machines, blackout curtains, sleeping masks, and fans can help block out distractions.
• Keep a Consistent Sleep Routine: For better sleep, stay on a regular sleep schedule. Even on the weekends, try to wake up and go to bed at consistent times every day.
• Avoid Food and Drinks That Impact Sleep: Stay away from caffeine in the afternoon and evening. Also, try to not drink alcohol or eat large meals too late in the day.
• Limit Electronics Before Bedtime: Computer screens, TVs, cell phones, and tablets emit light that can signal the brain to stay awake.
• Don’t Stay in Bed if You Can’t Sleep: Get out of bed if you can’t sleep after 30 minutes of trying. Instead, try reading, meditating, or doing another quiet activity until you feel sleepy.