Insomnia

Insomnia is a common sleep disorder that affects how you feel and function during the day. About 10% of people worldwide experience insomnia that qualifies as a medical condition, but there are many effective ways to improve your sleep.

Table of contents

• What is insomnia?
• Types of insomnia
• How common is insomnia?
• Symptoms of insomnia
• What causes insomnia?
• Who is at risk for insomnia?
• Health effects of insomnia
• How is insomnia diagnosed?
• Treatment options
• How to prevent insomnia

What is insomnia?

Insomnia is when you experience problems in how you feel or function because you aren’t sleeping well or sleeping enough^[1]. This can mean you have trouble falling asleep, staying asleep, or you wake up too early and cannot get back to sleep^[2]. As a result, you may get too little sleep or have poor-quality sleep, and you may not feel refreshed when you wake up^[6].

Your body needs sleep for many reasons. Experts know that when you don’t sleep enough, it can cause sleep deprivation (a condition where you don’t get adequate rest), which is usually unpleasant and keeps you from functioning at your best^[1].

Sleep habits and needs can be very different from person to person. Some people naturally prefer to go to bed and wake up early, while others prefer to go to bed and wake up late. Some people naturally need less sleep than others^[1]. Most adults need about 7 to 9 hours of sleep per night^[2].

Types of insomnia

Experts classify insomnia in different ways based on how long it lasts and what causes it^[1].

Based on time: Insomnia can be acute (short-term) or chronic (long-term). Acute insomnia is common and lasts from one night to a few weeks. It is usually caused by stress or a distressing event^[7]. Chronic insomnia lasts for three months or longer and happens at least three nights a week^[2].

Based on cause: Primary insomnia means it happens on its own and is not linked to any other health condition or problem. Secondary insomnia means you have trouble sleeping because of another health condition such as asthma, depression, arthritis, cancer, or heartburn, or because of pain, medication, or substance use^[1][7].

Insomnia can also be classified by when the problem occurs during the night. Initial insomnia means you have trouble falling asleep. Middle insomnia makes you wake up in the middle of the night but you fall back asleep. This is the most common form, affecting almost two-thirds of people with insomnia. Late insomnia means you wake up too early in the morning and don’t fall back asleep^[1].

How common is insomnia?

Both acute and chronic forms of insomnia are very common. Roughly 1 in 3 adults worldwide have insomnia symptoms, and about 10% of adults meet the criteria for insomnia disorder^[1]. An estimated 40 million Americans cope with insomnia each year^[8].

Insomnia affects women more often than men. Women are twice as likely to be diagnosed with insomnia^[4]. The problem becomes more common with hormonal changes, such as in the third trimester of pregnancy and after menopause^[4].

Insomnia can occur at any age but is particularly common in older adults, with symptoms present in as many as 65% of people 65 years or older^[4].

Symptoms of insomnia

You have insomnia if you regularly find it hard to go to sleep, wake up several times during the night, lie awake at night, wake up early and cannot go back to sleep, or still feel tired after waking up^[16].

Because you need sleep to be your best, disruptions like insomnia commonly cause symptoms during the day. You may find it hard to nap during the day even though you’re tired, feel tired and irritable during the day, or find it difficult to concentrate during the day because you’re tired^[16].

Insomnia can cause daytime sleepiness and a lack of energy. It also can make you feel anxious, depressed, or irritable. You may have trouble focusing on tasks, paying attention, learning, and remembering^[6]. It could also make you feel drowsy while driving, which could cause you to get into a car accident^[6].

What causes insomnia?

The causes of insomnia depend on whether you have primary or secondary insomnia. Many of these causes can be addressed, such as lifestyle habits and treating ongoing medical problems^[7].

The most common causes of insomnia include stress, anxiety or depression, noise, a room that’s too hot or cold, uncomfortable beds, alcohol, caffeine or nicotine, illegal drugs, jet lag, and shift work^[16].

Stress related to big life events like a job loss or change, the death of a loved one, divorce, or moving can cause insomnia. Your sleep environment, such as noise, light, or a room temperature that’s too hot or too cold, may hurt your sleep. Changes in your sleep schedule like jet lag, a new shift at work, waking up to care for a new baby, or moving to a new home can also cause problems^[7].

Eating too close to bedtime can leave you feeling uncomfortable when lying in bed and prevent sleep. Heartburn after eating can also interfere with sleep. Caffeine and nicotine are both stimulants that can keep you up if you consume them too soon before bedtime. Alcohol can interfere with your ability to get deep, restful sleep and may cause you to wake up during the night^[7].

Not getting enough exercise or other physical activity in the daytime can affect your sleep. Going to bed at different times rather than sticking to a regular sleep schedule, waking up at different times from day to day, taking naps during the day, being very active with too little time to relax before bedtime, and working or eating in bed can all lead to insomnia^[7].

Certain medical conditions and medicines can also cause insomnia. Mental health conditions such as schizophrenia or bipolar disorder, Alzheimer’s disease, Parkinson’s disease, restless legs syndrome, overactive thyroid, and menopause can all interfere with sleep. Long-term pain, sleepwalking, snoring or interrupted breathing while sleeping (sleep apnoea), nightmares, or night terrors can also keep you from getting a good night’s sleep^[16].

Who is at risk for insomnia?

You are at higher risk of insomnia if you have a lot of stress, are depressed or have other emotional distress such as divorce or death of a spouse, have a lower income, work at night or have frequent major shifts in your work hours, or travel long distances with time changes^[6].

People with certain medical conditions are at increased risk. Patients with conditions such as pulmonary disease, heart failure, neurologic disease, and painful conditions are at increased risk^[4]. An increased prevalence of insomnia is also associated with psychiatric disorders, including depression, anxiety, substance abuse, and post-traumatic stress disorder^[4].

Research shows that there may even be a genetic reason for some sleep differences. Some people naturally need less sleep than others, and a tendency for insomnia may run in families^[1][7].

Health effects of insomnia

Insomnia can have serious effects on your health. Sleep plays a very important role in keeping good mental and physical health. When your sleep is poor, your mood, motivation and quality of life are affected^[22].

Chronic insomnia raises your risk of high blood pressure, coronary heart disease, diabetes, and cancer^[3]. It can affect your memory and concentration^[3]. Insomnia is leading to billions of dollars of lost work productivity and increased risk of accidents^[8].

How is insomnia diagnosed?

To diagnose insomnia, your healthcare provider takes your medical history and asks for your sleep history. Your provider will ask you for details about your sleep habits^[6]. You may be asked to complete a questionnaire to show your sleep-wake pattern and your level of daytime sleepiness. You also may be asked to keep a sleep diary for a couple of weeks^[9].

Your health care professional may do a physical exam to look for signs of medical problems that may be related to insomnia. At times, a blood test may be done to check for thyroid problems or other conditions that may be related to poor sleep^[9].

If the cause of your insomnia is not clear, or you have signs of another sleep disorder such as sleep apnoea or restless legs syndrome, you may need to spend a night at a sleep center. A sleep study is done to keep track of and record various body activities while you sleep, including brain waves, breathing, heartbeat, eye movements and body movements^[9].

Treatment options

Healthy sleep habits

Changing sleep habits and taking care of any issues related to insomnia, such as stress, medical conditions or medicines, can result in restful sleep for many people^[9]. Simple changes in your daily habits often can help^[2].

Try to adopt the following bedtime habits to make it easier to fall asleep and stay asleep^[10]:

• Go to bed and wake up around the same time each day, even on weekends
• Make your bedroom sleep friendly: sleep in a cool, quiet, dark place
• Relax at least 1 hour before bed, for example, take a bath or read a book
• Make sure your bedroom is dark and quiet – use curtains, blinds, an eye mask or ear plugs if needed
• Exercise regularly during the day, but finish any vigorous exercise 3 to 4 hours before bed
• Make sure your mattress, pillows and covers are comfortable
• Avoid caffeine, nicotine, and alcohol close to your bedtime
• Avoid naps, especially in the afternoon
• Eat meals on a regular schedule and avoid late-night dinners
• Limit how much you drink close to bedtime
• Avoid watching TV or using devices like smartphones right before going to bed, because the blue light makes you more awake

Learn new ways to manage stress. Follow a routine that helps you wind down and relax before bed. For example, read a book, listen to soothing music, or take a hot bath. Your doctor may also recommend massage therapy, meditation, or yoga to help you relax^[10].

Cognitive behavioral therapy

Cognitive behavioral therapy for insomnia (CBT-I) can help you control or stop negative thoughts and actions that keep you awake. It’s usually recommended as the first treatment for insomnia^[9]. This specialized talking therapy focuses on establishing healthy sleep behaviours and addressing thoughts that can interfere with sleep^[15].

CBT-I may be face-to-face with a therapist, or through an online self-help programme. This can help you change the thoughts and behaviours that keep you from sleeping^[16]. One part of CBT-I is learning to have good sleep hygiene. You also focus on goals such as changing thoughts and behaviors that interfere with good sleep and creating a sleep schedule that gradually helps you sleep more over time^[12].

Medications

If lifestyle changes and CBT do not work, your doctor may recommend medicines to improve relaxation and sleep^[9]. Behavior and lifestyle changes can best help you improve your sleep over the long term. In some cases, though, taking sleeping pills for a short time can help you sleep^[12].

Doctors recommend taking sleep medicines only now and then or only for a short time. They are not the first choice for treating ongoing chronic insomnia^[12]. Your doctor may recommend prescription or nonprescription sleep medicines. Or you may take other medicines that can help you relax and fall asleep, such as benzodiazepines or antidepressants^[12].

Many sleep medicines cause side effects, such as low blood pressure, anxiety, and nausea. These medicines also may become less effective when your body gets used to them. They may cause withdrawal symptoms when you stop using them^[12]. Sleeping pills are only prescribed for a few days, or weeks at the most, if your insomnia is very bad or other treatments have not worked^[16].

How to prevent insomnia

Insomnia usually gets better by changing your sleeping habits^[16]. Following healthy sleep habits as described above can help prevent insomnia from developing or returning.

Set your body clock by going to sleep and waking up at roughly the same time every day, even on weekends. This routine will get your brain and body used to being on a healthy sleep schedule. In time, you’ll be able to fall asleep quickly and rest soundly through the night^[18].

Save your bed for sleep and intimate relations. Your bedroom should feel relaxing. Don’t sit in bed and work, surf the Internet, or watch TV^[18].

If you’re consistently having trouble falling or staying asleep, or if you’ve had trouble sleeping for months and your insomnia is affecting your daily life in a way that makes it hard for you to cope, see your doctor^[16]. Your doctor will try to find out what’s causing your insomnia so you get the right treatment^[16].