An Overview of Insomnia

Trouble falling or staying asleep could be a disorder

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Man lying awake in bed due to symptoms of insomnia
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Insomnia is characterized by an inability to obtain a sufficient amount of sleep to feel rested. It can be due to either difficulty falling or staying asleep. It may also result in waking earlier than desired. The sleep is often reported to be of chronically poor quality, light, and unrefreshing. As a result of this, people with insomnia suffer from daytime symptoms like poor attention, irritability, and reduced energy.

Fortunately, there are effective treatment options for insomnia, ranging from the temporary use of sleeping pills to cognitive behavioral therapy (CBT).

Symptoms

With insomnia, sleeping difficulties occur at least three nights per week for more than three months.

Insomnia negatively affects daytime functioning, leading to one or more of the following symptoms:

  • Fatigue or daytime sleepiness
  • Malaise (feeling unwell)
  • Poor attention or concentration
  • Impaired performance (errors, accidents)
  • Reduced energy or motivation
  • Behavioral problems (i.e., hyperactivity, impulsiveness, aggression)
  • Inability to nap
  • Headache, upset stomach, and chronic pain complaints

In addition to the above daytime symptoms, mood disorders, like anxiety or depression, are commonly associated with insomnia. Depression may be associated with early morning awakenings and difficulty returning to sleep. Anxiety may leave your mind buzzing at night, worries washing over you as you try to get to sleep. When sleep becomes difficult to obtain, this may fuel the fires of anxiety, making matters worse and fueling a vicious cycle.

Moreover, insomnia may affect serotonin levels and the function of the frontal lobe of the brain. The frontal lobe is responsible for various executive functions, which are key in making rational choices and appropriate social interactions. Impairment can be so significant that the ability to suppress suicidal thoughts, or even the outright impulse to kill oneself, may be lost.

Studies suggest that the risk of suicide may double among those with insomnia. Anyone with such thoughts should seek help by contacting the National Suicide Prevention Lifeline toll-free at (800) 273-8255.

Causes

Experts' understanding of the cause of insomnia is rooted in three factors: predisposition, provocation, and perpetuation.

Predisposition

Everyone has the potential to develop the kind of difficulty sleeping that characterizes insomnia. This is referred to as a predisposition or threshold. The threshold for developing insomnia will vary for each person.

Believe it or not, there are people who rarely or never develop trouble sleeping at night. On the other hand, some people may be unlucky and are simply predisposed to have insomnia. This likely relates to genetic factors (insomnia often runs in families), age, sex (more often women), substance use, and other medical and psychiatric conditions (e.g., depression, anxiety, or chronic pain disorders, like migraine or fibromyalgia).

Insomnia may also be attributed to an increased alerting signal. This relates to the sympathetic nervous system, which is responsible for the so-called "fight or flight" response. Some people may have an increased sympathetic drive, meaning they are primed to respond to an external threat. This signal can keep you awake during the day, but it also keeps people with insomnia up at night. Some have described this as being "tired but wired".

Provocation

Even though you might have a predisposition to insomnia, it has to be triggered. These triggers are called precipitating or provocative factors.

Examples of such factors include:

  • Drinking alcohol, caffeine, or smoking a cigarette before bed
  • Television or pets in the bedroom
  • Travel (causing jet lag)
  • Shift work
  • Stress from a lost job, financial problems, a divorce, or the death of a close friend or family member
  • Nighttime responsibilities, such as infant feedings

Keep in mind, typically when the cause is removed, insomnia abates. However, it can also become perpetuated by changes you make.

Perpetuation

The final components that transform a passing difficulty sleeping into chronic insomnia are called perpetuating factors. These factors can best be understood by considering an example.

Let’s imagine that you lie awake several hours in the middle of the night, a common occurrence in insomnia. You recognize that you need eight hours of sleep, and by lying awake you are cutting into this time. You decide to start going to bed two hours earlier to compensate. This may help some, but now that you are going to bed extra early it is taking you more time to fall asleep. As you lie awake more of the night, your frustration increases and you compound your initial insomnia.

In the end, there are a variety of choices that might perpetuate your insomnia. Some people choose to limit their daytime activities because of sleepiness. This avoidance may reduce your physical activity. Since you aren't exercising, you may be less tired and unable to sleep.

Alternatively, you may start working on your computer in bed to make the most of your time spent awake. The light from your computer and the activity may worsen your ability to sleep. Or, you may start napping during the day to get some rest, which could undermine your sleep drive and ability to sleep at night.

The existence of perpetuating factors prolongs your battle with insomnia.

Diagnosis

Insomnia is diagnosed usually based on a careful history alone. In some cases, a sleep log, multiple sleep latency test (MSLT), sleep-wake actigraphy, or a sleep study (polysomnogram) may provide corroborative evidence or be used to rule out other sleep conditions like circadian rhythm disorder or sleep apnea.

Treatment

If insomnia results in disrupted daytime function, especially if it persists chronically, it may require treatment.

Here are a few key interventions that healthcare providers, especially sleep specialists, use to treat insomnia.

Addressing Your Triggers

Many people's insomnia triggers resolve on their own. For example, a bad night of sleep before a school exam will go away as soon as the test is over.

Other triggers can be alleviated once they are properly identified and addressed. For instance, eliminating afternoon caffeine, avoiding alcohol as a "nightcap," and removing technology devices or disturbances within your sleep environment may be enough for you to get some quality shuteye.

If you are suffering from chronic insomnia, you may need to seek professional help. It can be very beneficial to address the beliefs, thoughts, and feelings that surround your insomnia with a treatment called cognitive behavioral therapy for insomnia (CBTI).

With CBTI, a specially trained psychologist will help you identify your unique triggers and then help you defuse them. For instance:

  • If you cannot fall asleep because you moved your bedtime up, sleep restriction—where you limit your time in bed and avoid daily naps—may be the recommendation.
  • If you lie awake at night and cannot get to sleep, stimulus control may be helpful.
  • If your mind races when you lie down, you may benefit from observing a buffer zone before bedtime or scheduling worry time during the day.

Lastly, if your insomnia is due to a more long-term trigger (e.g., shift work or jet lag from frequent travel), talk with your doctor about interventions that specifically target that trigger.

Taking Medication

There are many medications that can be effective in the short-term for treating insomnia. Two major classes include benzodiazepine and nonbenzodiazepine medications.

Some of these prescription and over-the-counter medications include:

The reason why the above medications should only be used short-term and not long-term is that sleeping pills may cause something called tachyphylaxis. With this phenomenon, the medication becomes less effective, so higher doses are needed for the same effect. Ultimately, the medication stops working, and when discontinued, rebound insomnia occurs.

Managing Coexisting Conditions

It is also very important to address any chronic issues that might be contributing to or associated with your insomnia, such as an underlying mood disorder (e.g., depression, anxiety, or post-traumatic stress disorder) or another sleep disorder (e.g., sleep apnea or restless legs syndrome).

Speak with your doctor about any symptoms you may be experiencing that cannot be explained by a diagnosis you've already been given, and work with him or her to adjust any treatment plans you are following that need fine-tuning to help you feel your best.

Consider a Complementary Therapy

Some people also find various complementary therapies helpful for treating their insomnia, such as:

A Word From Verywell

Insomnia is a common condition that can lead to significant impairment in one's quality of life and daily functioning. The good news is that there are numerous therapy options available, although your individual treatment plan will require a close look at your unique triggers and health profile. In the end, if you are struggling with insomnia, please speak with your doctor. Our Doctor Discussion Guide below can help you start that conversation to find the best treatment option.

Insomnia Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Woman
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