Insomnia Overview

Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An
estimated 30%-50% of the general population are affected by insomnia, and 10% have chronic
insomnia.
Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is
"difficulty initiating or maintaining sleep, or both" and it may be due to inadequate quality or
quantity of sleep. Insomnia is not defined by a specific number of hours of sleep that one gets,
since individuals vary widely in their sleep needs and practices. Although most of us know what
insomnia is and how we feel and perform after one or more sleepless nights, few seek medical
advice. Many people remain unaware of the behavioral and medical options available to treat
insomnia.
Insomnia is generally classified based on the duration of the problem. Not everyone agrees on
one definition, but generally:

symptoms lasting less than one week are classified as transient insomnia,

symptoms between one to three weeks are classified as short-term insomnia, and

those longer than three weeks are classified as chronic insomnia.

Statistics on Insomnia
Insomnia affects all age groups. Among adults, insomnia affects women more often than men.
The incidence tends to increase with age. It is typically more common in people in lower
socioeconomic (income) groups, chronic alcoholics, and mental health patients. Stress most
commonly triggers short-term or acute insomnia. If you do not address your insomnia, however,
it may develop into chronic insomnia.

Insomnia Causes
Insomnia may be caused by a host of different reasons. These causes may be divided into
situational factors, medical or psychiatric conditions, or primary sleep problems. Insomnia could
also be classified by the duration of the symptoms into transient, short-term, or chronic.
Transient insomnia generally last less than seven days; short-term insomnia usually lasts for
about one to three weeks, and chronic insomnia lasts for more than three weeks.
Many of the causes of transient and short-term insomnia are similar and they include:

Jet lag

Changes in shift work

Excessive or unpleasant noise

Uncomfortable room temperature (too hot or too cold)

Stressful situations in life (exam preparation, loss of a loved one, unemployment, divorce,
or separation)

Presence of an acute medical or surgical illness or hospitalization

Withdrawal from drug, alcohol, sedative, or stimulant medications

Insomnia related to high altitude (mountains)

Chronic or long-term insomnia

The majority of causes of chronic or long-term insomnia are usually linked to an underlying
psychiatric or physiologic (medical) condition.
Psychological related insomnia
The most common psychological problems that may lead to insomnia include:

anxiety,

stress,

schizophrenia,

mania (bipolar disorder), and

depression.

In fact, insomnia may be an indicator of depression. Many people will have insomnia during the
acute phases of a mental illness.
Physiological related insomnia
Physiological causes span from circadian rhythm disorders (disturbance of the biological clock),
sleep-wake imbalance, to a variety of medical conditions. The following are the most common
medical conditions that trigger insomnia:

Chronic pain syndromes

Chronic fatigue syndrome

Congestive heart failure

Night time angina (chest pain) from heart disease

Acid reflux disease (GERD)

Chronic obstructive pulmonary disease (COPD)

Nocturnal asthma (asthma with night time breathing symptoms)

Obstructive sleep apnea

Degenerative diseases, such as Parkinson's disease and Alzheimer's disease (Often

insomnia is the deciding factor for nursing home placement.)

Brain tumors, strokes, or trauma to the brain

High risk groups for insomnia

In addition to the above medical conditions, certain groups may be at higher risk for developing
insomnia:

travelers

shift workers with frequent changing of shifts

seniors

adolescent or young adult students

pregnant women, and

menopausal women

Medication related insomnia

Certain medications have also been associated with insomnia. Among them are:

Certain over-the-counter cold and asthma preparations.

The prescription varieties of these medications may also contain stimulants and thus
produce similar effects on sleep.

Certain medications for high blood pressure have also been associated with poor sleep.

Some medications used to treat depression, anxiety, and schizophrenia.

Other causes of insomnia

Common stimulants associated with poor sleep include caffeine and nicotine. You
should consider not only restricting caffeine and nicotine use in the hours immediately
before bedtime but also limiting your total daily intake.

People often use alcohol to help induce sleep, as a nightcap. However, it is a poor choice.
Alcohol is associated with sleep disruption and creates a sense of nonrefreshed sleep in
the morning.

A disruptive bed partner with loud snoring or periodic leg movements also may impair
your ability to get a good night's sleep.

Primary Sleep Disorders

In addition to the causes and conditions listed above, there are also a number of conditions that
are associated with insomnia in the absence of another underlying condition. These are called
primary sleep disorders, in which the sleep disorder is the main cause of insomnia. These
conditions generally cause chronic or long-term insomnia. Some of the diseases are listed below:

Idiopathic Insomnia (unknown cause) or childhood insomnia, which start early on in

life and results in lifelong sleep problems. This may run in families.

Central Sleep Apnea. This is a complex disorder. It can be the primary cause of the
insomnia itself or it may be caused by other conditions, such as brain injury, heart failure,
high altitude, and low oxygen levels.

Restless leg syndrome (a condition associated with creeping sensations in the leg during
sleep that are relieved by leg movement)

Periodic limb movement disorder (a condition associated with involuntary repeated leg
movement during sleep)

Circadian rhythm disorders (disturbance of the biological clock) which are conditions
with unusual timing of sleep (for example, going to sleep later and waking up late, or
going to sleep very early and getting up very early).

Sleep state misperception, in which the patient has a perception or feeling of not
sleeping adequately, but there are no objective (polysomnographic or actigraphic)
findings of any sleep disturbance.

Insufficient sleep syndrome, in which the patient's sleep is insufficient because of

environmental situations and lifestyle choices, such as sleeping in a bright or noisy room.

Inadequate sleep hygiene, in which the individual has poor sleep or sleep preparation
habits (described in the following treatment section.)

Insomnia Symptoms
Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms
intertwine with those of other medical or mental conditions.

Some people with insomnia may complain of difficulty falling asleep or waking up
frequently during the night. The problem may begin with stress. Then, as you begin to
associate the bed with your inability to sleep, the problem may become chronic.

Most often daytime symptoms will bring people to seek medical attention. Daytime
problems caused by insomnia include the following:
o Poor concentration and focus
o Difficulty with memory
o Impaired motor coordination (being uncoordinated)
o Irritability and impaired social interaction
o Motor vehicle accidents because of fatigued, sleep-deprived drivers

People may worsen these daytime symptoms by their own attempts to treat the
symptoms.
o Alcohol and antihistamines may compound the problems with sleep deprivation.
o Others have tried nonprescription sleep aids.

When to Seek Medical Care

When to call the doctor

A person with insomnia needs a doctor's attention if it lasts longer than three to four
weeks, or sooner if it interferes with a person's daytime activities and ability to function.

Insomnia may be a symptom of another medical or psychological problem, which a

patient may need to address first or at the same time.

When to go to the hospital

Generally, a patient will not be hospitalized for most types of insomnia. However,
accidents may result from poor coordination and attention lapse seen with sleep
deprivation.

Worsening pain or increased difficulty breathing at night also may indicate a person need
to seek emergency medical care.

Exams and Tests

The doctor will begin an evaluation of insomnia with a good medical history.

The doctor will seek to identify any medical or psychological illness that may be
contributing to the patient's insomnia. A thorough medical history and examination
including screening for psychiatric disorders and drug and alcohol use is paramount in
evaluation of a patient with sleep problems.
o For example, the patient may be asked about chronic snoring and recent weight
gain. This may direct an investigation into the possibility of obstructive sleep
apnea. In such an instance, the doctor may request an overnight sleep test
(polysomnogram). Sleep studies are frequently done in specialized "sleep labs" by
doctors trained in sleep medicine, frequently working under pulmonary (lung)
specialists. This test is not part of the routine initial workup for insomnia,
however.

o The diary will include the patient's personal assessment of their alertness at
various times of the day on two consecutive days within the two week period.

The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used
to assess daytime sleepiness.

Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are
small, wrist-worn devices (about the size of a wristwatch) that measure movement. They
contain a microprocessor and on-board memory and can provide objective data on
daytime activity.

Insomnia Treatment
In general, transient insomnia resolves when the underlying trigger is removed or corrected.
Most people seek medical attention when their insomnia becomes more chronic.
The main focus of treatment for insomnia should be directed towards finding the cause. Once a
cause is identified, it is important to manage and control the underlying problem, as this alone
may eliminate the insomnia. Treating the symptoms of insomnia without addressing the main
cause is rarely successful.
The following therapies may be used in conjunction with therapies directed towards the
underlying medical or psychiatric cause. They are also the recommended therapies for some of
the primary insomnia disorders.
Generally, treatment of insomnia entails both non-pharmacologic (non-medical) and
pharmacologic (medical) aspects. It is best to tailor treatment for individual patient based on the
potential cause. Studies have shown that combining medical and non-medical treatments
typically is more successful in treating insomnia than either one alone.

Non-medical treatment and behavioral therapy

Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus
control, and sleep restriction. These also referred to as cognitive behavioral therapies.
Sleep hygiene
Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple steps
can be taken to improve a patient's sleep quality and quantity. These steps include:

Sleep as much as you need to feel rested; do not oversleep.

Exercise regularly at least 20 minutes daily, ideally 4-5 hours before your bedtime.

Avoid forcing yourself to sleep.

Keep a regular sleep and awakening schedule.

Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.)
Avoid "night caps," (alcoholic drinks prior to going to bed).

Do not smoke, especially in the evening.

Do not go to bed hungry.

Adjust the environment in the room (lights, temperature, noise, etc.)

Do not go to bed with your worries; try to resolve them before going to bed.

Relaxation therapy
Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the
lights and playing soothing music prior to going to bed.
Stimulus control
Stimulus control therapy also consists of a few simple steps that may help patients with chronic
insomnia.

Go to bed when you feel sleepy.

Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep and
sexual activity.

If you do not fall asleep 30 minutes after going to bed, get up and go to another room and
resume your relaxation techniques.

Set your alarm clock to get up at a certain time each morning, even on weekends. Do not
oversleep.

Avoid taking long naps in the daytime.

Sleep restriction

Restricting your time in bed only to sleep may improve your quality of sleep. This therapy is
called sleep restriction. It is achieved by averaging the time in bed that the patient spends only
sleeping. Rigid bedtime and rise time are set, and patient is forced to get up even if they feel
sleepy. This may help the patient sleep better the next night because of the sleep deprivation for
the previous night. Sleep restriction has been helpful in some cases.
Other simple measures that can be helpful to treat insomnia include:

Avoid large meals and excessive fluids before bedtime

Control your environment.

o Light, noise, and elevated room temperature can disrupt sleep. Shift workers and
night workers especially must address these factors. Dimming the lights in the
bedroom, relaxation, limiting the noise, and avoiding stressful tasks before going
to bed may be beneficial. (Refer to sleep hygiene and relaxation therapy above.)
o Avoid doing work in the bedroom that should be done somewhere else. For
example, do not work or operate your business out of your bedroom and avoid
watching TV, reading books, and eating in your bed.

A person's body's circadian rhythm (biological clock) is particularly sensitive to light. Parents
who need to sleep during the day may have to make child care arrangements to allow them to
sleep.

Medications and Medical Therapies

There are numerous possible medications to treat insomnia. Generally, it is advised that they
should not be used as the only therapy and that treatment is more successful if combined with
non-medical therapies. In a study, it was noted that when sedatives were combined with
behavioral therapy, more patients were likely to wean off the sedatives than if sedatives were
used alone.

Benzodiazepine sedatives: six of these sedative drugs have been used to treat insomnia.
There are reports of subjective improvement of quality and quantity of sleep when using
these medications. These include temazepam (Restoril), flurazepam (Dalmane), triazolam
(Halcion), estazolam (ProSom, Eurodin), lorazepam (Ativan), and clonazepam
(Klonopin).

Nonbenzodiazepine sedatives: These include eszopiclone (Lunesta), zaleplon (Sonata),

and zolpidem (Ambien).

Melatonin: Melatonin is secreted by the pineal gland, a pea-sized structure at the center
of your brain. Melatonin is produced during the dark hours of the day-night cycle
(circadian rhythm). Melatonin levels in the body are low during daylight hours. The
pineal gland responds to darkness by increasing melatonin levels in the body. This
process is thought to be integral to maintaining circadian rhythm. At night, melatonin is
produced to help your body regulate your sleep-wake cycles. The amount of melatonin
produced by your body seems to decrease as you get older. Melatonin may be beneficial
in patients with circadian rhythm problems.

Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors.

Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders.
Ramelteon is approved by the Food and Drug Administration (FDA) for treatment of
insomnia characterized by difficulty falling asleep.

Some antidepressants [for example, amitriptyline (Elavil, Endep) and trazodone

(Desyrel)] have been used for the treatment of insomnia in patients with co-existing
depression because of some sedative properties. Generally, they may not be helpful for
insomnia in people without depression.

Antihistamines with sedative properties [for example, diphenhydramine (Benadryl) or

doxylamine] have also been used in treating insomnia as they may induce drowsiness, but
they do not improve sleep and should not be used to treat chronic insomnia.

Valeriana officinalis (Valerian) is a popular herbal medication used in the United States
for treating insomnia, however, to date there are no convincing studies to show any real
benefit in patients with chronic insomnia.

Next Steps
Follow-up

Follow the doctor's recommendations for the patient's medical and psychological conditions. The
patient will be asked to give their doctor feedback after they have followed a treatment plan.
Often the patient will have more than one option and more than one medication available to help
them. A patient should not lose hope if the first medication does not give them the results they
want or if they experience side effects or concerns. Report back to a doctor for advice.

Prevention

The following are suggestions to help anticipate and modify situations likely to be associated
with insomnia. They are not foolproof, nor will they safeguard the patient from the consequences
of sleep deprivation once it has occurred.
Insomnia from jet lag

Behavioral and short-term drug therapy has been used.

If you can anticipate a trip, begin to shift your bedtime to coincide with the time schedule
in your destination.

Short-acting tranquilizers (benzodiazepines) have been shown to be useful. Melatonin, a

hormone secreted by the pineal gland that regulates our sleep-wake cycles, has also been
used.

Insomnia from shift changes

Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep
deprivation in shift workers.

You should shift your schedules forward in a clockwise direction - from days to evening
to night shift - and allow sufficient time to adapt (at least one week) between shift
changes.

Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as a
rhythm synchronizer.

Shift workers should stress the importance of good sleep habits with regular bedtime and
awakening.
o Supplemental naps may be necessary to ensure work time alertness.
o Discuss the use of naps with a doctor.
o Some people promote using short-acting sedatives in the first few days following
a shift change, but not everyone agrees.

Insomnia from acute stresses

Stress may be positive or negative, and concerns about sleep may vary. Many stressors
will go away with support and reassurance.

Education about the importance of good sleep habits is also helpful.

Some people may need short-term treatment with medications. A doctor will often work
toward the lowest effective dose with a short-acting sedative to achieve proper sleep.

General recommendations include the following:

Work to improve your sleep habits.

o Learn to relax. Self-hypnosis, biofeedback and relaxation breathing are often
helpful.
o Control your environment. Avoid light, noise, and excessive temperatures. Use the
bed only to sleep and avoid using it for reading and watching TV. Sexual activity
is an exception.
o Establish a bedtime routine. Fix wake time.

Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and
reduce the use of stimulants including caffeine and nicotine.

If you do not fall asleep within 20-30 minutes, try a relaxing activity such as listening to
soothing music or reading.

Limit daytime naps to less than 15 minutes unless directed by your doctor.
o It is generally preferable to avoid naps whenever possible to help consolidate your
night's sleep.
o There are certain sleep disorders, however, that will benefit from naps. Discuss
this issue with your doctor.

Outlook
Recovery from insomnia can vary.

If you have insomnia caused by jet lag, your symptoms will generally clear up within a
few days.

If you are depressed and have had insomnia for many months, it is unlikely that your
symptoms will go away on their own. You may need further evaluation and treatment.

Your outcome will also depend on coexisting medical conditions, which may include
congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic
pain syndromes.

Synonyms and Keywords

sleeplessness, stress, anxiety, depression, sleepless, chronic insomnia, acute insomnia, mental
illness, sleep habits, insomniac, insomnia, difficulty sleeping, sleep, disorders that disrupt sleep,
difficulty falling asleep, primary insomnia, sleep test, polysomnogram, obstructive sleep apnea,
insomnia medications, daytime sleepiness, melatonin, nonbenzodiazepine sedatives, pineal
gland, jet lag, shift change, parasomnias

Authors and Editors

Author: Saimak T. Nabili, MD, MPH

Editor: Melissa Conrad Stoppler, MD
Previous contributing authors and editors:
Author: Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop
University Hospital; Associate Professor, Department of Clinical Pediatrics, State University of
New York at Stony Brook.
Coauthor(s): Harbhajan Singh, MD, Chief of Pulmonary Medicine, Director, Department of
Respiratory Therapy, South Nassau Communities Hospital.
Editors: Joseph A Salomone III, MD, Associate Professor, Department of Emergency Medicine,
Truman Medical Center, University of Missouri at Kansas City School of Medicine; Francisco
Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard Harrigan, MD, Associate
Professor, Department of Emergency Medicine, Temple University Hospital, Temple University
School of Medicine.

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The following Viewer Comments have not been medically reviewed. See additional information.
Comment from: DavidA, 45-54 Male (Patient)

For years I have had trouble falling and staying asleep or wakening and unable to fall back
asleep. I have a particularly stressful job and I would change my circumstance if I could afford to
do so, but that's not happening anytime soon. I am a coffee drinker and though I have quit and
resumed many times, I never found that avoiding caffeine helped my issue. I also have mild
depression and these days have had success in minimizing it. I take OTC antihistamine to help
me fall asleep, and that works 80% of the time, but there are times where nothing seems to help.
I have tried everything from prescriptions to melatonin supplements. Even recently I had a pulled
muscle where the hydro-codeine painkiller could not even help me fall asleep. When I awake in
the night I have mentioned jokingly to coworkers that the "committee" called a meeting to
discuss all things worrisome. Published: September 10 ::