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Insomnia

(Sleeplessness)

Definition

Insomnia is a sleep disorder. It may cause a number of sleep problems including trouble falling asleep, waking in the middle of the night or waking very early in the morning. It may also be a sleep that is not restful. Insomnia can be a short-term problem, or it can be chronic. Chronic insomnia lasts for more than 4 weeks.

Causes

Insomnia can occur for many reasons. Short-term insomnia is often caused by temporary situations or problems with the environment. They may include:
  • A life crisis or stress, including the loss of a life partner, divorce, or loss of a job
  • Environmental noise
  • Extreme temperatures (like a room that is too hot or too cold)
  • Change in the surrounding environment
  • Sleep/wake schedule problems, such as those due to jet lag
There may be no clear reason for chronic insomnia. It may also be due to other medical or psychiatric conditions. Examples of these conditions that can lead to sleep problems include:
Both chronic and short-term insomnia may be due to
  • Behavioral factors, including:
    • Misuse of caffeine, alcohol, smoking cigarettes, or other substances
    • Disrupted sleep/wake cycles from shift work or other nighttime activities
    • Chronic stress
    • Excessive napping in the afternoon or evening
  • Certain medicines such as:
    • Allergy medicines
    • Corticosteroids
    • Blood pressure medicines
    • Psychiatric medicines

Risk Factors

Factors that increase your chance of getting insomnia include:
  • Age: adults 50 years or older are more likely to have insomnia
  • Sex: female (especially during and after menopause)
  • Stress
  • A history of mental disorders (such as anxiety, depression)
  • Chronic pain
  • Having chronic medical conditions
  • Using alcohol, drugs, or certain medicines
  • Shift work
  • Use of multiple medicines

Symptoms

Symptoms include:
  • Difficulty falling asleep
  • Waking up frequently during the night with difficulty returning to sleep
  • Waking up too early
  • Not feeling refreshed after sleep
  • Daytime sleepiness
  • Irritability, anxiety, inability to concentrate

When Should I Call My Doctor?

Call your doctor if you are having frequent insomnia. Let your doctor know if the insomnia is making it hard for you to do your daily activities.

Diagnosis

The doctor will ask about your symptoms and medical history. A physical exam will be done. You will also be asked about your job, eating habits, and drug and alcohol use.
The doctor will also ask about your schedule and sleep patterns. You may be asked to keep a sleep diary. This will include information about your naps, bedtime, and how often you wake during the night. Your doctor will review the medicines you take, including over-the-counter medicines and herbal supplements. These questions will help your doctor understand what is causing your insomnia.

Laboratory Testing

Your doctor may recommend observation in a sleep lab. This may be done if the diagnosis is uncertain or if other sleep disorders are suspected. You will need to spend the night in a special center. Your movements, breathing, and brain activity are monitored. This will allow your doctor to identify a treatable condition that is affecting your sleep.
Monitored Breathing During Polysomnography
Sleep monitor apnea
Copyright © Nucleus Medical Media, Inc.

Treatment

Treat Underlying Medical Conditions

A number of physical and mental disorders can disrupt sleep. Diagnosis and treatment of the underlying illness, may fix the insomnia.

Identify and Modify Behaviors That Worsen Insomnia

There are steps you can take to improve your chance of a good night's rest. Your doctor may ask you to reduce intake of certain items or avoid them all together to see if your sleep improves. You may be asked to:
  • Reduce or avoid caffeine especially late in the day
  • Reduce or avoid alcohol and drug use.
  • Quit smoking. If you smoke, avoid doing so near bedtime.
  • Avoid eating or drinking close to bedtime.
Your sleep habits can also affect how well you sleep. Steps that may help you sleep better include:
  • Go to bed and wake up at the same time each day.
  • If you must take naps, keep them short.
  • Only use the bedroom for sleep or sex. Avoid watching TV or worrying in bed.
  • Keep your bedroom at a comfortable temperature and dark. Minimize disruptions such as pets.
  • If you work at night and sleep during the day, make sure to block daylight from the room. Decrease the amount of noise. Use a fan to block out noise.

Medications

Sleeping pills are available by prescription or over-the-counter (OTC). Some doctors advise against the long-term use of sleeping pills. They may cause dependence. This is a physical change in your body. It makes your body dependent on the drug for sleep.
Proper use of prescription sleep medicine may increase sleep. Most of these medicines are only approved for short-term use. They can cause drowsiness, dizziness and headache. Serious side effects can include abnormal thinking or behavior changes including having suicidal thoughts.
Many OTC sleep medicines contain diphenhydramine (Benadryl). This medicine can make you feel groggy and might help you fall asleep. However, this drug can have serious side effects. Most people should avoid using this drug regularly. Elderly persons in particular may have a variety of adverse effects to this drug. They should discuss its use with their doctor.

Exercise

Exercise can help you get a better sleep. It can reduce stress and allow your body to reach a deeper relaxation. The timing of exercise is important. Exercising early in the day may be best if you are having trouble sleeping. If you have to exercise later in the day, make sure you are done exercising at least a few hours before bedtime.

Herbal Therapies and Supplements

Some people use the herb valerian to reduce insomnia. Others take melatonin. It is not clear that these supplement help. Talk to your doctor before taking an herbs or supplements.

Relaxation Therapy

This therapy may reduce or eliminate anxiety and body tension. It stops the mind from racing and allows the muscles to relax. This can support a restful sleep. The therapy may include deep breathing and progressive relaxation.

Sleep Restriction

A sleep restriction program is a strict sleep program. It limits the amount of time in bed to only the time that you are actually sleeping. Previous sleep logs will determine the amount of time allowed in bed. The time you spent sleeping will be used to determine the amount of time you can spend in bed. At first, your time in bed may seem short, usually about five hours. Gradually, the time is increased until a more normal night's sleep is achieved.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of talk therapy. This means that you discuss your thoughts, feelings, and behaviors with a mental health professional. CBT focuses on how the way you think affects the way you feel and act. CBT may have more lasting effects than medicine. CBT is usually applied over six weeks, with maintenance therapy given as needed.

Reconditioning

Reconditioning helps people associate the bed and bedtime with sleep. This means not using the bed for activities other than sleep and sex. As part of the reconditioning process, the person is usually advised to go to bed only when sleepy.

Prevention

To reduce your chance of having insomnia:
  • Minimize intake of caffeinated food and drinks after lunch (like coffee, tea, chocolate, cola drinks).
  • Avoid drinking alcohol.
  • Avoid eating too fast or too much. Do not eat too close to bedtime.
  • Avoid drinking fluids before bedtime.
  • Do not smoke.
  • Exercise regularly, but not within less than three hours of bedtime.
  • Use the bedroom only for sleep and sex. Do not use electronics or watch TV while in bed
  • Schedule relaxing bedtime routines. Listen to quiet music or soak in warm water.
  • Make sure that the bedroom is not too cold or too hot.
  • Use a humidifier or dehumidifier as needed.
  • Get sunlight during the day.
  • Use shades or lined drapes; or wear an eye mask to reduce sleep disruption.
  • Use earplugs, or listen to relaxing music or white noise. This helps reduce the disturbing effects of noise.
  • Make sure your mattress is supportive and the bedding is comfortable.
  • Avoid "clock watching" after going to bed.
  • Keep bedtimes and wake-times consistent throughout the week.
  • If you cannot avoid naps, keep them short.

RESOURCES

National Center on Sleep Disorders Research http://www.nhlbi.nih.gov

National Sleep Foundation http://www.sleepfoundation.org

CANADIAN RESOURCES

Better Sleep Council Canada http://www.bettersleep.ca

The Canadian Sleep Society http://www.canadiansleepsociety.com

References

American Sleep Apnea Association website. Available at: http://www.sleepapnea.org. Accessed July 1, 2009.

Insomnia. EBSCO DynaMed website. Available at: https://dynamed.ebscohost.com/about/about-us . Updated July 9, 2012. Accessed August 14, 2012.

Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004 Sep 27;164(17):1888-96. http://archinte.jamanetwork.com/article.aspx?articleid=217394

Insomnia. Family Doctor.org. Available at: http://familydoctor.org/familydoctor/en/diseases-conditions/insomnia.html. Accessed August 14, 2012.

Insomnia. EBSCO Publishing Health Library, Natural and Alternative Treatments website. Available at: http://www.ebscohost.com/healthLibrary/. Accessed March 8, 2012.

Insomnia: quick answers to medical diagnosis and therapy. Access Medicine website. Available at: http://www.accessmedicine.com.ezp-prod1.hul.harvard.edu/quickam.aspx . Accessed November 8, 2009.

Insomnia and sleep. National Sleep Foundation website. Available at: http://www.sleepfoundation.org/article/sleep-related-problems/insomnia-and-sleep. Accessed August 14, 2012.

Morin CM, Vallieres A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301(19):2005-2015.

National Center on Sleep Disorders Research website. Available at: http://www.nhlbi.nih.gov/about/ncsdr/index.htm. Accessed August 14, 2012.

Sleep insomnia, lack of sleep. National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/inso/. Published March 2009. Accessed August 14, 2012.

Revision Information

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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