Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

Insomnia

(Sleeplessness)
by Amy Scholten, MPH
Definition

Insomnia is a poor quality sleep. This may mean a lack of sleep or difficulty staying asleep. Some have trouble falling asleep, or problems waking in the middle of the night or very early in the morning. It may be characterized as:

  • Adjustment insomnia (acute insomnia): transient—lasts from a single night to a few weeks
  • Intermittent or short term insomnia—episodes of transient insomnia occur from time to time
  • Primary insomnia (chronic insomnia): occurs on most nights and lasts a month or more; usually needs treatment
Causes

There are many causes.

Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following:

  • Hormonal shifts during the menstrual cycle, pregnancy, perimenopause, or menopause
  • Side effects of medicine
    • Prescription: steroids, theophylline , phenytoin (Dilantin), levodopa
    • Nonprescription: diet aids, decongestants, cold and cough remedies
  • A life crisis or stress, including the loss of a life partner, divorce, or loss of a job
  • Change in the surrounding environment (one of the most common causes)
  • Environmental noise
  • Extreme temperatures (like a room that is too hot or too cold)
  • Sleep/wake schedule problems such as those due to jet lag

Chronic insomnia sometimes results from the following conditions:

Chronic insomnia may also be due to behavioral factors, including:

  • Misuse of caffeine, alcohol , or other substances
  • Chronic stress
  • Disrupted sleep/wake cycles from shift work or other nighttime activities

In addition, the following behaviors have been shown to perpetuate insomnia in some people:

  • Excessive napping in the afternoon or evening
  • Expecting to have difficulty sleeping and worrying about it—usually starts in young adults
  • Smoking cigarettes before bedtime
Insufficient Sleep Syndrome

This results from a person not getting enough sleep due to life circumstances. The person may be working more than one job or working and going to school at the same time. As a result they do not get enough sleep every day, over a longer period of time. This may lead to daytime sleepiness. It can also lead to problems with focus and muscle aches and pains.

Risk Factors

Factors that increase your chance of getting the condition include:

Symptoms

Symptoms include:

  • Irritability, anxiety , inability to concentrate, unexplained symptoms like muscle aches or pains
  • Difficulty falling asleep
  • Feeling unrefreshed after sleep
  • Waking up frequently during the night with difficulty returning to sleep
  • Waking up too early
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 travel 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, to see if any of these may be contributing to your insomnia.

Laboratory Testing
Polysomnography

Certain types of insomnia or severe daytime sleepiness may be observed in a sleep lab. This is called polysomnography . You will 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.

Your doctor may also check to make sure that your thyroid is functioning properly.

Treatment
Treat Underlying Medical Conditions

A number of physical and mental disorders can disrupt sleep. Diagnosis and treatment of underlying illness, such as restless legs syndrome , may prevent insomnia.

Identify and Modify Behaviors That Worsen Insomnia
  • Do not smoke close to bedtime.
  • Go to bed and wake up at the same time each day.
  • If you must take naps, keep them short.
  • Reduce or avoid caffeine, alcohol, and drug use.
Medications

Sleeping pills are available by prescription or over the counter. Some doctors advise against the long-term use of sleeping pills. They may cause dependence.

Proper use of prescription sleep medicine can be effective. They should not interfere with memory, work functioning, or daytime drowsiness.

Most over-the-counter sleep medicines contain diphenhydramine (Benadryl). This antihistamine will help many people fall asleep more rapidly. It will probably improve sleep quality. Elderly persons may have a variety of adverse effects to this drug. They should discuss its use with their doctor.

Herbal Therapies and Supplements

Some people use the herb valerian to reduce insomnia. Others take melatonin . In the US, these products do not undergo the same testing as drugs. Their long-term impact, side effects, and possible interactions with other drugs or medical conditions are often unknown.

Relaxation Therapy

This may reduce or eliminate anxiety and body tension. It stops the mind from racing and allows the muscles to relax so that restful sleep can occur. It may include deep breathing, stopping thought, and using progressive relaxation.

Sleep Restriction

A sleep restriction program at first allows only a few hours of sleep during the night. This is 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:

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

Last reviewed: September 2011 by J. Thomas Megerian, MD, PhD, FAAP.

RESOURCES:
CANADIAN RESOURCES:
References:
  • American Academy of Sleep Medicine website. Available at http://www.aasmnet.org/PatientsPublic.aspx . Accessed July 1, 2009.
  • American Sleep Apnea Association website. Available at: http://www.sleepapnea.org/ . Accessed July 1, 2009.
  • Borge Sivertsen; Siri Omvik; Stale Pallesen; et al. Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults: A Randomized Controlled Trial. JAMA . 2006;295(24):2851-2858.
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  • 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 July 1, 2009.
  • Sleep insomnia, lack of sleep. National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/inso/inso_whatis.html . Published March 2009. Accessed July 1, 2009.