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There are a million causes of insomnia and a million ways it plays out in the nights of individual sleepers. The most common sleep disorder, insomnia is what people mean when they say they are having trouble sleeping, or aren’t sleeping well. A more formal name is Difficulty Initiating and Maintaining Sleep (DIMS).
Insomnia can be classified along two different characteristics: duration and overall sleep pattern.
|Sleep-onset insomnia||Takes a long time to get to sleep, but can sleep through the night once sleep starts|
|Sleep-maintenance insomnia||Wakes frequently during the night and sleep is fragmented|
|Short-term or acute insomnia||Less than three months|
|Transient or adjustment insomnia||However long it takes for the circadian cycle to catch up with one’s environment|
|Chronic or long-term insomnia||More than three months|
Until recently, insomnia was also subdivided into two separate classifications based on the origin of the disorder: primary insomnia and secondary insomnia. Primary insomnia referred to difficulty sleeping that arose independently in a patient, regardless of other medical or psychological conditions or disorders. Secondary insomnia, on the other hand, was defined as insomnia that directly from medical or mental illness, bodily injury, medication side effects, and other conditions known to cause sleep disruption.
|Primary||When the insomnia arises independently|
|Secondary||When insomnia arises due to illness, injury, medication side effects, or other factors|
The terms ‘primary insomnia’ and ‘secondary insomnia’ were eliminated in 2015 following revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is considered one of the most authoritative sources of information in this field. The newest definition simply denotes the condition as ‘insomnia’, and emphasizes the importance of treating insomnia as a disorder, regardless of whether it has arisen independently or due to other conditions or factors; if the insomnia is co-morbid with another illness or disorder, then this condition should also be addressed and treated. The American Academy of Sleep Medicine followed suit, noting the same changes in its latest edition of the International Classification of Sleep Disorders (ICSD-3). When asked to comment, the editor of ICSD-3 simply stated, “Insomnia is insomnia is insomnia”.
Additionally, the latest editions of the DSM-5 and ICSD-3 state that three months of consistent sleep disruption is the most appropriate benchmark for a chronic insomnia diagnosis. Previously, this benchmark was only one month.
Symptoms of insomnia include sleepiness, fatigue, decreased alertness, poor concentration, decreased performance, depression during the day and night, muscle aches and an overly emotional state (i.e. being cranky). Temporary insomnia can be brought on by stress, illness, pain, diet, medications and disruptions to circadian rhythms.
Insomnia results in a degradation in quality of life. Bad insomnia can make a person miserable. The economic costs of insomnia to society are huge.
Chronic insomnia can be so distressing that a study found it worsened “health-related quality of life” almost as much as clinical depression and congestive heart failure.
Insomniacs suffer excessive daytime sleepiness which saps their productivity and capacity for enjoyment. Insomniacs are more likely to be involved in automobile and industrial accidents. Insomnia makes all the little irritations and maladies in life seem so much worse. When you get sick, the insomnia on top of it compounds how bad you feel, and may extend the length of your illness. Total health care costs are 60% higher for people with insomnia than for good sleepers, although it should be recognized this is not a cause-and-effect phenomenon.
Insomnia is known to be co-morbid with mental illness. A study found that chronic insomniacs whose insomnia was not resolved within a year had a 34% chance of developing a psychiatric disorder. For those whose insomnia disappeared, the chance was only 13%. How the causation runs is not clear and probably not consistent from cases to case. The insomnia could be an early symptom of the psychiatric disorder or a trigger for it, or some other relationship could be in play.
When you ask a large group of people if they have insomnia many will answer “yes” – more than actually have insomnia by a formal definition. Self-reporting is notoriously unreliable for getting accurate numbers for public health. Polls show 95% of adults report experiencing insomnia at some point in their life and 33% report insomnia in the previous year. Of course, self-reporting in notoriously unreliable.
The National Institutes of Health estimate that 26% of American adults have some sort of mental illness at one point over the course of a year. Estimates like this are all over the place and depends a lot on definition and self-reporting. A European organization says 38% of Europeans have some sort of a mental disorder and that includes 7% with insomnia.
It depends on the definition of insomnia, of course. The large majority of individuals have at least the occasional bad night’s sleep, and in a folk or day-to-day understanding of sleep issues, that means they have insomnia. But any formal definition of insomnia includes some requirement for daytime impairment. According to Dr. Thomas Roth, incorporating this requirement reduces the prevalence to 10%. Adding the even more stringent requirement that the symptoms persist for a month, the prevalence drops to 6%.
What makes insomnia a “disorder”? A condition is a disorder if it has negative consequences and if those consequences are a pathological response rather than a normal part of the condition. Insomnia is a disorder and also a symptom and also a precursor/cause. The folk definition of insomnia – a bad night’s sleep – does not necessarily constitute a disorder. But under the formal diagnosis created by medical associations, insomnia is indeed a disorder.
Rebound insomnia is when you can’t sleep after coming off sleeping pills. Your brain and body have adjusted to the sleep medication and almost anticipate it. The feedback mechanisms have had their set points adjusted, to some extent. The set points change back of course, but in the short run your body experiences insomnia in response to the lack of drug. A related phenomenon is “rebound pain” that people experience when they stop taking pain relievers. Some people experience both rebound pain and rebound insomnia if they have been taking something like Tylenol PM, which contains both a pain reliever and an antihistamine.
Rebound insomnia also occurs in people taking drugs for reasons other than insomnia. For instance, an opioid given for severe pain will affect the patient’s sleep as will a benzodiazepine given for anxiety. When these drugs are discontinued, the patient may notice trouble sleeping through the night.
Rebound insomnia is very common, and a reason to avoid medication if possible. One way to reduce it is to wean yourself off the drug. Reduce the dosage over a few nights to permit your body to slowly get used to sleeping without the medicine. You can also try other methods of getting to sleep: good sleep hygiene, exercise, warm milk. Even a different type of sleeping pill would probably work, but doctors would almost certainly not recommend using one sleep aid to counteract rebound insomnia caused by stopping a different sleep aid. Consult a doctor if you feel this is the only way. You can visit our page on sleep medicines for more information.
You sometimes hear the term “altitude insomnia” when people can’t sleep after climbing a mountain (or flying to a city like Denver.) More formally, there is a condition called Acosta’s syndrome, or hypobaropathy, or altitude sickness, which can have many symptoms, including sleeplessness. Sensitive individuals experience this when they go up as little as 2000 ft in elevation.
While in extreme cases altitude sickness can be serious, most people suffer through the discomfort and adjust in a few days. The easiest solution to this sickness is to simply return to the lower starting elevation, at which point symptoms usually clear rapidly.
Substance use refers to alcohol, stimulants, drugs (both recreational and medicinal), and accidental ingestions of external items. Substances are often used together, compounding the effect and making identifying the cause of the sleeplessness difficult. See our page on alcohol and sleep. Both nicotine and marijuana use alter sleep patterns.
The same substance can have opposite effects on different individuals: caffeine seems to help some people fall asleep while it keeps others up. Poisons can also interrupt sleep and a symptom of low-dose poisoning is insomnia. These poisons could include anything from spider venom to lead.
Adjustment sleep disorder refers to insomnia caused by a change in life, such as stress or environmental change. It is distinct from jet lag and shift-work sleep disorder in that there is no forced change in sleep times. The body has trouble changing to the new situation, physically or psychologically. This is often a transient insomnia if the stress disappears or the sleeper adapts.
Some psychologists and medical doctors use the phrase non-restorative sleep (abbreviated NRS), but this terminology has not been officially adopted by any formal body. It generally means the feeling at waking of not being refreshed. Plenty of people experience it, but it doesn’t necessarily mean it fits the clinical definition of a sleep disorder the way difficulty initiating and maintaining sleep (insomnia) does.
Note that a person who experiences non-restorative sleep can sleep through the night, so it is not a type of insomnia, but the person will experience excessive daytime sleepiness, the major daytime symptom and downside of insomnia.
People with diseases such as chronic fatigue syndrome experience this phenomenon. The connection between the immune system and the drive for sleep may explain why sick people always feel tired and sleepy. It is not that they don’t get enough sleep or enough slow-wave (deep) sleep. It’s that even with enough sleep their brain’s sleepiness meter does not reset. People with seasonal affective disorder (SAD) are in the same boat.
Some Canadian researchers have proposed a non-restorative sleep scale (NRSS) to quantify the subjective severity of lack of refreshment after apparently normal sleep. People with mental illness often complain of non-restorative sleep as do those with fibromyalgia and chronic fatigue syndrome. While these people often have daytime sleepiness too, the feeling of insufficiently refreshing sleep is common enough that doctors and psychologists are starting to consider non-restorative sleep as a separate symptom.
It remains to be seen whether the proposed 10-question Canadian scale catches on with diagnosticians, or if another such scale becomes a diagnostic standard.
This type of insomnia is called paradoxical because it is not really insomnia in an objective sense, at least to an external observer. People who complain about not being able to sleep but whose EEG readings show they are sleeping normally are said to have paradoxical insomnia. A more formal name is Sleep State Misperception. (A less charitable name is sleep hypochondriasis). Sufferers are convinced they failed to sleep through much of the night. They usually do not have daytime sleepiness a person who failed to sleep through the night would have. When asked to estimate how much of the night they spent asleep, people with this condition vastly underestimate their real time as measured by instruments. They also overestimate the sleep latency period between bedtime and when they actually get to sleep. It has been found that individuals with sleep state misperception tend to have higher metabolic rates.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has no classification for this phenomenon. It is not known what causes paradoxical insomnia or how prevalent it is. Sometimes people who have had chronic insomnia, when they start sleeping normally, still have paradoxical insomnia. It has been suggested that paradoxical insomnia is a precursor to psychophysiological insomnia.
This is a term given when the insomnia is caused by a mix of physical and psychological factors. Given sleep’s importance for our minds and bodies it is not surprising that multiple causes could contribute to sleep fragmentation.Insomnia during pregnancy and insomnia after menopause are two common examples of psychophysiological insomnia.
Physiological events that cause transient insomnia can kick off a vicious cycle. Rather than disappearing in a few days, the insomnia worsens as the sufferer worries about getting enough sleep. Daytime sleepiness may prompt him or her to go to bed earlier, resulting in greater sleep latency and possible sleep onset insomnia. The bed becomes associated, in the person’s mind, with a place of unrest and struggle for sleep. Pills can be tried, but even if they work, they lead to rebound insomnia when stopped. The person muddles on with new fixes, new bad feelings about the bedroom, and continued poor sleep.
Sleep onset insomnia is trouble falling asleep. Sleep maintenance insomnia is trouble staying asleep throughout the night.
Short periods of nighttime waking occur even in some good sleepers, but retrograde amnesia kicks in and in the morning the person does not remember waking. These short periods that do not bother the subject do not constitute sleep maintenance insomnia.
In chronic sleep onset insomnia, when the person also has difficulty getting up in the morning, the situation can be classified as delayed sleep phase syndrome. In this case, the person’s clock is off: when the body wants to sleep is not the same as when the mind wants to sleep. More frequent and pedestrian sleep onset insomnia is just caused by having a lot on your mind or by being nervous. Sleep onset insomnia is more common in young adults while sleep maintenance insomnia is common in the elderly. Delayed sleep phase syndrome usually strikes in adolescence, so it makes sense that young adults are more prone to sleep onset insomnia.
Sleep maintenance insomnia results in frequent and prolonged nocturnal awakenings, especially in the second half of the night. In some sense, sleep maintenance insomnia may be an artifact of our social expectations of a night of uninterrupted sleep. There is good evidence for a more natural pattern being a bi-phasic one and an attempt to suppress the normal mid-night waking period may lead to fragmented sleep through a longer section of the night.
What can you do about sleep maintenance insomnia? Keeping good sleep habits and maintaining a diary might be a good start. Pharmaceutical companies are aware of the sleep maintenance insomnia problem and trying to develop drugs that address the condition. The drugs on the market today are more effective for sleep onset insomnia. The dosage of sleep aids is set with an aim for a full night’s sleep. Too little and the patient is more likely to wake during the night. Too much and the person will have morning hangover and grogginess.
Is insomnia a disease or a disorder or an illness? It’s certainly an illness because anything that is uncomfortable or bothersome counts as an illness. Some illnesses are also diseases. Some diseases are caused by infectious agents or parasites; some are due to lack of adequate nutrition or genes.
A disorder is a functional abnormality. Disorders are sometimes kicked off by a pathogen or external trauma, but there does not need to be an infectious agent to keep the disorder going.
Diseases can often be cured. Disorders can usually not be cured, although medicine often provides techniques for managing them. This meshes with our experience of insomnia, which can be treated but often returns. Sometimes the insomnia does disappear after treatment, but sleeping pills are not believed to cure the insomnia on their own. Rather, the insomnia disappears independently while the pills help relieve the worst of the symptoms.
Scientists are increasingly seeing insomnia as a consequence of hyperarousal during the day. That is, the problem isn’t that people aren’t getting sleepy enough to fall asleep; it’s that they are too stimulated the rest of the day. In the war between sleepiness and arousal, the arousal wins too often in the insomniac’s brain. (This is one reason there are hopes for arousal-killing orexin antagonist drugs.)
The hyperarousal idea isn’t just speculation. Modern imaging techniques can show how much energy the brain is using (more precisely, how much glucose is in the blood in different areas of the brain). Many (not all) insomniacs have higher energy consumption in the brain during waking and NREM sleep compared to good sleepers. Further insomniacs tend to have smaller reductions in energy use from waking to non-REM sleep in areas of the brain rich in wake-promoting neurons.
Of course, the etiology of insomnia varies from person to person. There are many causes and many ways insomnia plays out in our daily lives. Further, in long term chronic insomnia cases, the insomnia almost always changes, evolving in response to seasonal changes, medicines taken, psychological factors (rumination on how hard it is to sleep), and other variables.
This is one reason patients with insomnia should take charge of their sleep management. Your doctor can be involved, but of necessity he or she will not be able to monitor your insomnia as it progresses.
The regulation of sleep is still a mystery, although some of the underlying neurochemical factors have been identified. The circadian and homeostatic processes in the two-process model are valid and provide a good understanding and explanation of patterns and observed behavior. But there are other factors not included in this simple model that can disrupt sleep or lead to a pattern that looks like insomnia.
Treatment for insomnia can include medication or behavioral strategies, or a combination of the two.
Transient insomnia usually won’t necessitate treatment. Short-term or occasional insomnia may not be worth treating with medication either, since the risks associated with prescription pills may outweigh the benefits. And the first step for anyone having trouble sleeping is to ensure their sleep hygiene is up to snuff. After that, if the insomnia is enough of a problem for a person, then they may want to consider over-the-counter sleep aids, prescription medicine, or cognitive behavioral therapy.
Both over-the-counter and prescription sleep medicines work to help people get to and stay asleep. Like other drugs, they work more for some people than others.
Medical professionals are ambiguous about recommending or prescribing sleeping pills. Some have no reluctance, thinking of sedatives and hypnotics as technologies that are practical and safe and effective when used correctly. Others feel pills are a surrender – an admission that the underlying etiology could not be found or directly addressed. Pills are a fix even if an unsatisfying one for getting to the root of the problem.
All insomnia pills have side effects. All. As with any drug, different people react differently, and sometimes the side effects are not significant compared to the benefits the patient derives. Sleeping pills on the market today are safer than the barbiturates used 50 years ago. The main side effects of modern pills are drowsiness when you don’t want to be drowsy (difficulty getting up and staying alert in the morning) and a disruption in the sleep cycle. You’ll still have all stages of the sleep cycle when you take the drug, but it may cause you to stay in stages 1 and 2 longer than healthy person with a normal sleep pattern would.
Sedatives and hypnotic drugs are prescribed to produce drowsiness and to promote sleep
Drugs that are anxiolytic and sedative-hypnotic alter the continuum of excitability in the brain. At low doses, many patients have a greater sense of well-being and decreased arousal. At higher doses, people become sleepy and their cognitive physical performance deteriorates.
An anxiolytic is any drug or therapy used in the treatment of anxiety disorders that works on the central nervous system to relieve the symptoms of anxiety. Anxiolytics are not “minor tranquilizers”.
Insomnia is one of the most common complaints people present to their doctors, but from a medical standpoint, it can be difficult to address. If insomnia cannot be treated with non-drug therapies, the use of sleep medications may be helpful. These medicines are almost always prescribed only for short times. They tend to disrupt natural sleep patterns. Prolonged use of sleeping pills can result in tolerance and physical dependence. There may be an increased risk of cancer from long-term use, although this connection is not clear. More tips on taking sleeping aids.
Insomnia is a problem for many people, and there are many different ways to attack it, such as through exercise and changing the patient’s sleeping patterns. Another option for management is via pharmaceuticals, both over-the-counter (OTC) and prescription. OTC medications tend to be used for infrequent and/or mild cases of insomnia, whereas prescription drugs are usually used for chronic and moderate-to-severe situations. Physicians have the freedom to prescribe all sorts of different medicines, including those that are “off-label” for sleep disorders.
The National Health and Nutrition Examination Survey found About 4% of U.S. adults aged 20 and over used prescription sleep aids in the past month. Use is higher in older people and those with more formal education.
Sleeping pills produce sedation. When sedated, your brain can go through the sleep cycles. But drugs don’t force the onset or advancement of the sleep cycles.
The challenge for the drug developers is always to maximize sleep, minimize side effects and residual effects that produce sleep inertia, and improve (or at least not degrade) sleep architecture. Researchers today are excited about drugs that address different neurotransmitter systems – not just the old benzodiazepine system. The hope is that the new drugs will have less addiction potential and improve sleep quality by increasing the amount of time the person spends in deep sleep every night. However, arguments about the overprescription of sleep medications still persist.
Almost all sleep aids exert effects on neurotransmitters, either by affecting the breakdown, reuptake, or binding to a cell receptor (antagonists). Drugs can also mimic neurotransmitters (agonists). Antihistamines block the effects of a neurotransmitter on the postsynaptic receptor. Benzodiazepines are agonists and stimulate the postsynaptic receptor.
The effects can be complex, but the neurotransmitters either make the postsynaptic neuron more likes to fire (excitatory) or less likely to fire (inhibitory).
As far as prescription drugs, the Food and Drug Administration (FDA) approves four drug classes for the treatment of insomnia: benzodiazepines, benzodiazepine receptor agonists, melatonin receptor agonists, and orexin receptor antagonists. Over-the-counter sleep aids are almost always antihistamines and melatonin. Prescription drugs such as antidepressants and antipsychotics may be prescribed “off-label”, meaning the doctor may write a prescription with the intent of improving sleep quality or duration, but the FDA has not explicitly approved these drugs for sleep disorders.
These are the go-to medicines that most doctors prescribe for insomnia. They are sometimes referred to as “Z-drugs“.
Benzodiazepines were developed as anti-anxiety drugs. The main benzodiazepine in the 60’s was Valium, which was the top selling prescription drug in the country for several years. These medicines enhance the activity of the inhibitory neurotransmitter GABA. Because they effectively permit people who take them to get to sleep, they found use as sleeping pills. Benzodiazepines with short half-lives were developed to produce sleeping pills that did not leave the user with a sedated hang-over the next morning.
Although doctors sometimes prescribe benzodiazepines for insomnia, newer drugs are usually preferred. Benzodiazepines are still widely used for anxiety.
Low doses of antipsychotic drugs are sometimes used for insomnia.
This is a new class of drugs under development. Suvorexant is the only medicine in this class on the market.
At one time, tricyclic antidepressants were the go-to prescription for doctors when patients complained about insomnia. The off-label, first-line use of antidepressants for treating insomnia in the absence of depression is now considered debatable. (Nonbenzodiazepine drugs are now the most common.)
Chloral hydrate is rarely used for sleep disorders anymore.
Over-the-counter sleeping pills use antihistamines as their active ingredient. Some widely used ones include:
Scientists and researchers are constantly exploring new pharmacological treatments for insomnia. Check out our page on emerging drugs for insomnia.
Chronobiotics is a catch-all term that has been around for a while for drugs that affect the circadian pacemaker. Melatonin is the most well-known chronobiotic, but many other drugs – approved and experimental – could be classified in this category. These drugs include other indoleamines, cholinergic agents, peptides, and benzodiazepines.
Ideally, a chronobiotic would be used to get people “back on track” — especially when they have jet lag or shift-work sleep disorder.
Sleep experts recognize that sleep disorders often result in people using prescription and non-prescription drugs that may cause side effects that exacerbate sleep disturbances.
Morphine and similar opioid drugs cause selective decreases in rapid-eye-movement (REM) sleep through actions on brainstem cholinergic neurons, neurons known to participate in the initiation of this sleep state.
Mysteries remain, but brain scients are making progress into understading the, neurotransmitters and neuromodulatory substances involved in falling and staying asleep. We’re also learning more about the biochemical underpinnings involved in the circadian rhythm. Already we have seen the arrival of melatonin agonists on the market and the advancement of orexin antagonists through the development process It is an exciting time for insomnia medication.
The best insomnia treatments do not involve drugs. We are not anti-drug at Tuck. Medicines are a technology humans have developed to help us, and appropriate use of medicines can assist millions and should not be looked down upon. But the considered opinion of thoughtful public health officials is that if you can avoid drugs in addressing your sleeping problems, so much the better.
The risk of dependency (both physical and psychological, however mild), the cost, the changes in sleep architecture which all sleeping pills produce – these are enough to prefer non-pharmaceutical intervention if it works.
Drug interactions are another reason to avoid sleeping pills, if you already take another pill regularly. Although drug companies, the FDA, and the larger medical community attempt to anticipate negative interactions among different drug combinations, they cannot always do so.
Many people don’t like pharmaceuticals because they consider using drugs to get to sleep to be a crutch. The crutch analogy is somewhat misplaced. If drugs truly were like a crutch for a broken leg that would be better. The broken bone clutch is an explicitly temporary device to aid the patient until the bone heals enough to allow unaided walking. If sleeping pills were used in that way – to help people sleep during a transient period of insomnia, that would be ideal. Unfortunately, many patients can not or will not end use of the drugs.
Everyone should practice good sleep hygiene anyway, and when sleep problems first become noticeable, the things to check include temperature and darkness of the bedroom, comfort of the beddings, clothing, and regular schedule for bedtime and rising time.
Although time consuming and expensive, cognitive behavioral therapy is widely considered to be the most effective treatment for mild to moderate insomnia for the long run. In these days of trying to get the cost of healthcare down, CBT is often forgotten when drugs can work so much faster and cheaper.
This refers to medicine for other things, not sleep disorders.
Many drugs cause insomnia as a side effect, and if the insomniac notices sleep disturbances upon starting or modifying a medicine, it is worth mentioning this to the prescribing doctor. It may be possible to get another medicine that does not interfere with sleep.
Light therapy (or phototherapy) is employed mainly for circadian disorders, which are a common cause of insomnia. Light therapy is totally drug-free, and involves a light-emitting box located next to the bed. Light is important in so much of our circadian cycles, so exposure to light can help sleep patterns get back on track.
Sleep restriction therapy is particularly effective for some with sleep maintenance insomnia, as it forces the waking periods to be shorter and the brain to be sleepier throughout the night. The increased sleepiness counteracts the hyperarousal that may be the cause of sleep maintenance insomnia.
Intentionally limiting time in bed so that the insomniac has fewer chances to lie awake is proven to help battle insomnia, and involves no medication. This is related to CBT, and should always be done under the supervision of a therapist.
Another technique is called paradoxical intention. The person takes care to establish good sleep hygiene but tries to lie in bed and NOT fall asleep.
Formal relaxation therapy helps some people get into a state conducive to sleep before they go to bed. Lullabies are arguably a form of relaxation therapy for small children and music can be useful for adults, too.
CPAP machines are used to help people with sleep-disordered breathing. They are not specifically FDA-approved for insomnia, but because breathing problems induce sleep maintenance insomnia, CPAPs can help. They are quite expensive, and although covered by many insurance policies, the coverage is generally only if you have been diagnosed with apnea.
Taking a break from life’s routine usually helps people sleep. On vacation, especially away from home in a relaxing setting, many people can sleep better, and more. Often the vacationer finds it easy to sleep in daytime naps, so even if the nighttime sleep is not improved, total sleep time increases.
Although vacations can help people repay their sleep debt and get back on a good sleep schedule, overly long vacations (or retirement and unemployment) are not always a good idea because the lack of structure leads to too much sleep.
We have a separate page on exercise and sleep. It is overly simplistic to say exercise helps you sleep, although generally people in better health have better sleep. A good rule-of-thumb is to exercise during the day, but limit your physical activities to light stretching in the evenings before bedtime.
Eating a big meal can help many get to sleep. Many people employ alcohol partly to help with insomnia, although this method can backfire on you and is not viable in the long run.
Some people find these relaxing. They can help relax the muscles and promote sleep. It is possible that the thermoregulation system, so tied into the sleep cycle, is affected by the warmth and subsequent cooling that happens when the person gets out of the tub. Hypnosis is also a possible therapy for insomnia.
Some people swear by the ancient practice of acupuncture for a range of maladies, including insomnia. There is no scientific evidence for the effectiveness of acupuncture. A recent meta-study (evaluation of other studies) at Emory University concluded that although most showed some positive effects of acupuncture, the studies were not set up according to scientific standards and their results could not be accepted as scientifically valid.
Similarly, another meta-study by Penn State University psychiatrists found that acupuncture studies were for the most part flawed (a common occurrence in alternative medicine investigations) but that the available evidence did support efficacy of the procedure for alleviation of insomnia. They called for a larger, more systematic study of acupuncture for sleep disorders.
Don’t imagine herbs are somehow exempt from the commercial forces that drive conventional medicine. This is a multi-billion dollar business worldwide.
A Beijing University study found traditional Chinese medicine (herbs) were useful in treatment of senile dyssomnia. Compared to modern medicine, the success rate was about the same and the side effects were lesser.
Engaging in boring mental activity is an age-old method of inducing sleep. Indeed, the proliferation of personal electronic devices and easy home entertainment is blamed for shortening sleep times in modern society.
Melatonin is probably the most widely known plant product used for insomnia. We have a separate page on melatonin.
A recent meta-study by University of Melbourne researchers found that alternative medicine evaluations did not live up to the standards of formal science.
The website for National Center for Complementary and Integrative Health says relaxation techniques and melatonin can be useful for sleep disorders, but “the evidence for other complementary approaches is either inconsistent or too limited” for that organization to recommend their use.
Therapies such as chronotherapy, phototherapy, and biofeedback are employed for insomnia.
Changing your diet can have some small effect on sleep. We don’t put a lot of stock in stuff like acupressure, tai chi, and yoga, although some find them useful, or claim to. This might be a placebo effect, but if it works, a placebo effect is welcome. Herbal remedies do not have much science to support them.
There are different kinds, causes, and manifestations of insomnia. If you know or strongly suspect the cause, you may be able to take steps to remedy it, or your body may adjust and the insomnia may be transient.
These are some steps for dealing with insomnia. To learn more, visit our page on fixes for insomnia.
Problem: Takes too long to fall asleep after going to bed. Feel fine during day. No daytime sleepiness.
Solution: You probably don’t have a problem. You don’t need as much sleep as you allow time in bed for. Go to bed later or get up earlier.
Problem: Wake up too early in the morning. Feel fine during day. No daytime sleepiness.
Solution: You probably don’t have a problem. In all likelihood, you simply don’t need as much sleep as you allow time in bed for. Go to bed later or get up earlier.
Problem: Wake up for a half hour or more in the middle of night. Wide awake during this time. Feel fine during day. No daytime sleepiness.
Solution: The easiest thing to do it to accept this pattern as your sleep routine. You are not alone. Many adults have a biphasic sleep pattern. Get out of bed during this period and do something.
Problem: Need a drink or two before bed to get to sleep. Without a drink, lie in bed for a long time before falling asleep.
Solution: You might have a problem if you feel like you need that alcohol. Try without it for a few weeks, though it might take longer for your body to adjust. NEVER mix sleeping pills (even over-the-counter medications) and alcohol.
Problem: Frequent short awakenings during the night. Sleepy during part or all of the day.
Solution: You might have sleep maintenance insomnia.
Problem: Wake up wheezing or short of breath fairly often.
Solution: Consult a doctor as soon as possible. Sleep-disordered breathing requires intervention and you need professional medical help.
Problem: Take a very long time to get to sleep at night. Drowsy during the day.
Solution: You probably have sleep onset insomnia.
When faced with insomnia, try these methods in the order listed.
1) Improve sleep hygiene
2) Start keeping a sleep diary and see if it helps you find causes and solutions
3) Sleep restriction. A professional therapist will be expensive, but if you have enough self-discipline, you can create and execute your own program.
4) After three months, medication may be the best option. Over-the-counter sleep aids, used responsibly (don’t mix with alcohol or other drugs) help millions. Try to limit your use to two weeks, though the drug schedule will vary by specific medication.
5) Medical help from doctor. Cognitive behavioral therapy has been shown to be the best long-term solution for insomnia (and it’s drug free), but it is expensive, and you might have trouble finding a therapist. CBT may also not be covered under your health insurance plan. To reduce cost and hassle, most people probably prefer a pill. Doctors can discuss options with you. Some of the prescription sleeping pills are habit-forming. You don’t want to stay on them in the long run. Work with your doctor to taper off medications. If CBT is feasible, try that.
6) A sleep clinic diagnosis requires overnight polysomnography. If your insurance won’t pay for this it could be expensive. These tests could uncover apnea or other sleep disorders.
Think of this as “learning to sleep correctly.” The insomniac is taught to eliminate or ignore stimuli that prevent sleep. The method tries to teach the subconscious mind that at a certain time (bed time) and in a certain location (the bedroom) it is time to sleep. These ideas are good for everyone, not just those with chronic insomnia.
Practices include intentionally removing activities from the bedroom that conflict with sleep. Restrict bed activities to sleep and sex, and refrain from reading, eating, or watching television anywhere in the bedroom. Insomniacs are instructed to avoid lying awake in bed for an extended period of time — if sleep does not come, the person should get out of bed and leave the room.
Sleep hygiene describes beneficial behaviors and negative routines that can affect one’s sleep. Areas covered include the sleep environment, sleep schedules at night, daytime napping, amounts of stimulating foods and beverages consumed, overly rigid bedtime routines, general health behaviors, and timing of exercise. For instance many sufferers try to fall asleep, but despite being unable to do so, continue to lie in bed hour after hour watching the clock. Positive sleep hygiene encourages you to get out of bed after 20 minutes or so, and to engage in a sleep-promoting behavior like reading. Once you feel drowsy again, you get back into bed for another try. Continuing to lie in bed increases anxiety and makes sleep even less likely. As the insomniac learns about the positive and negative effects of specific behaviors on sleep quality and length, good habits can be formed.
Some would include relaxation techniques as a type of stimulus control.
Stimulus control works better for reducing sleep latency than for preventing nighttime awakenings. It is therefore more effective in cases of sleep onset insomnia than sleep maintenance insomnia. Stimulus control can have long lasting effects if the patient stays with it. And staying with it is the key. Doctors know this type of therapy is more likely to be effective in highly motivated patients who will take charge of their insomnia management. Patients who are unwilling or unable to improve their sleep management may be better off with medication.
|Neurotransmitter||Class of Drug||Examples||Comments|
|H1 Histamine||Antihistamines (aka histamine antagonists)||Diphenhydramine, Doxylamine||Over-the-counter sleep medicines are antihistamines|
|GABA (Gamma-Amino Butyric acid)||Benzodiazepines||Temazepam (Restoril) Triazolam (Halcion), Loprazolam (Havlane)||Still prescribed for insomnia, although more often for anxiety|
|GABA (Gamma-Amino Butyric acid)||Non-benzodiazepines: Pyrazolopyrimidines, imidazopyridines and cyclopyrrones – The”Z-drugs”||Eszopiclone (Lunesta), Zolpidem (Ambien), Zaleplon (Sonata)||Most prescriptions for insomnia involve this class|
|GABA (Gamma-Amino Butyric acid)||Barbituates||Secobarbital (Seconal)||Rarely used anymore|
|Orexin (Hypocretin)||Orexin antagonists||Suvorexant||Became available for patient use in 2015|
|Melatonin MT1 and MT2 receptors||Melatonin agonists||Melatonin, Ramelteon (Rozerem)||Affect the circadian clock. Usually have fewer side effects.|
|Serotonin and Dopamine||Antipsychotics and Antidepressants||Quetiapine (Seroquel), Olanzapine (Zyprexa), Doxepine (Sinequan)||Not often prescribed for sleep disorders, but for other disorders than have insomnia or hypersomnia as a symptom.|
|Opioid||Narcotics||Hydrocodone, Morphine||Pain medicines. Not prescribed for sleep disorders, but cause extreme drowsiness|
One way to consider insomnia is not a lack of sleepiness, but too much wakefulness – hyperarousal. Hyperarousal can result from many causes, of psychological and physiological origin. It’s a heightened awareness both day and night – being “high-strung” – and scientists have shown that chronic insomniacs have a higher metabolic rate than good sleepers. So in this model, each person has two forces in them – a drive toward sleep and a drive toward arousal – and the problem in insomnia isn’t that the drive toward sleep is too weak, it’s that the drive toward arousal is too strong. There is evidence that people with insomnia have longer times on the MSLT during the day (i.e. it takes them longer to fall asleep) despite complaining of sleepiness This fits with the model of too much alertness. Some researchers even created a Hyperarousal Scale and it was found that insomniacs tend to score high on it. The brains of insomniacs also tend to use more glucose.
Although the question is not settled, evidence continues to accumulate that insomnia involves high activity in both the sleep and arousal systems. Post-traumatic stress disorder patients also have high rates of insomnia that seem due to hyperarousal. Advanced medical imaging has shown that wholebrain metabolic activity is higher in people with insomnia in both daytime and night. Further the frontal lobes of the brain are particularly active during waking in insomniacs.
And what is this “arousal”? Arousal – the energetic state at any time – is a complex physiological state influenced by endocrine and neurologic systems. Stress hormones are part of it, and the largely unknown workings of the central nervous system. The recently discovered orexin system is part of the arousal/waking circuit. Another neuropeptide, melanin-concentrating hormone (MCH), is produced in the lateral hypothalamus portion of the brain, along with orexin. Like so many bodily phenomena, arousal has a homeostatic component to it – a moderating and smoothing influence – even if levels of arousal change over the course of the day. The environment has a great deal of influence on a person’s arousal level, and many neurotransmitters, cytokines, and hormones are part of the system.
Epidemiologists speak of “risk factors” for diseases and illnesses. Risk factors for insomnia is almost a meaningless term because insomnia is so common and because there are so many causes and co-morbidities. Any list of risk factors would include advanced age, being a woman, life changes (e.g. losing a job), mental illness, high alcohol and caffeine consumption, other illnesses, chronic pain, and side effects of various medications.
When risk factors are in place, precipitating factors can start an insomnia episode. Precipitating factors can be as simple as a change in daylight savings time or work schedule. Often it is a stressful event the person experiences in his or her work, school, or family life – so-called psychosocial stressors. Stress is a common cause of short-term insomnia, and the short-term sleep loss can ignite a cycle of long-term insomnia. Medication can be a precipitating factor, as can other illnesses.
Another paradigm sometimes used among sleep therapists is the 3P model: Predisposing, Precipitating, and Perpetuating Factors. Perpetuating factors are patterns and behaviors that form during the insomnia and which paradoxically keep the person from returning to good sleep, even after the precipitating factors are gone. For instance, anxiety about getting to sleep may have developed and may persist even after the nominal cause of the insomnia disappears. Bad sleep habits may be in place, or the insomniac may have started taking an OTC sleep aid and feel unable to quit it, getting rebound insomnia when an attempt to quit is made. Alcohol and drug use can also perpetuate insomnia.
Practitioners of CBT often have the 3P model in mind and use it as a framework or part of a framework for addressing insomnia and getting the patient back into a good long-term sleeping pattern.
Insomnia can be a self-fulfilling prophecy. Rumination and worry can cause insomnia – along with depression – and are consequences of insomnia. Anxiety about getting to sleep in the past can contribute to difficulties getting to sleep tonight. Worry is a perpetuating factor that keeps the insomnia going. When psychological and physical causes are both involved, the result can be called psychophysiologic insomnia. This happens a lot. Maybe a physical ailment will cause insomnia; when the ailment clears up the mind still enforces the insomnia because it has learned to not sleep at certain times or in a certain place. Worry about sleeping and a shift in the time actual sleep is obtained (causing de facto jet lag) make it all the harder to get back on track. It’s a self-reinforcing system.
Insomnia is not an inherited condition, but some predispositions that can lead to insomnia can be genetic. Recent investigation into the human genome has found epigenetic mechanisms involved in both sleep regulation and insomnia.
A large population study found that insomnias tend to be physically smaller than normal sleepers: they have smaller skeletons and less lean body mass. Incidence of obesity is also higher. Insomnias are more often underweight and overweight. They also have a different blood analysis profile: levels of albumin are lower and insulin and triglycerides are higher. The ?-glutamyl transferase enzyme, frequently used as a diagnostic marker, is also higher in insomniacs, and this incidence, along with high insulin levels, can suggest diabetes. The study found insomniacs have diabetes in higher numbers than normal sleepers.
Insomniacs also tend to have high calcium levels in the blood – which has been shown to be associated with cognitive decline in the long run.
It’s accepted that genetics affect sleep patterns and at least somewhat determine which chronotype (e/g/ a morning lark, a night owl) a person is. What’s less clear is how genetics affects an individual’s response to sleep deprivation. As with alcohol, where some people can handle their alcohol without as many visible outward signs, some people seem better able to function when sleep deprived.
The PER3 gene is known to influence the circadian system, and one variant is associated with a lower homestatic sleep drive. While scientists do not say there is a direct connection, the findings imply people with this variant PER3(4/4) are vulnerable for insomnia. Scientists found a gene mutation named hDEC2-P385R which is a a transcriptional repressor and has been found to cause individuals to be short sleepers.
The federal government’s latest (2011) sleep disorders research plan articulates among its goals identification of genetic factors that influence the risk of sleep disorders. It is not easy to figure out the genetics and heritability of insomnia and other problems and scientists appear to be a long way from getting there although some clues have been discovered.
Insomnia has many causes, and we shouldn’t forget some people have a great natural tendency to insomnia.
Despite evidence of a genetic predisposition to insomnia, some larger studies are required to say how much inheritance plays in DIMS (a formal name for Difficulty in Instituting and Maintaining Sleep). Family history should not be surprising as a factor given that other factors correlated with insomnia include an uptight nervous disposition, a particular metabolism and body type, and a tendency to hyperarousal, which all have a genetic component.
A survey has shown people with a family history of insomnia tend to score higher on formal measures of predisposition to arousal and symptoms of anxiety. People with a history of insomnia reported family sleep problems at a greater rate than those who never had insomnia.
Study of siblings supports the hypothesis of a genetic component. As measured by the Ford Insomnia Response to Stress Test (FIRST) siblings have correlated tendencies to insomnia. Because siblings tend to be raised together, it could be argued that there is an environmental component in this finding.
Canadian researchers looking at the incidence of new cases of sleep onset insomnia in a large population identified 5 risk factors:
Another large study found people with insomnia were more likely to have a first-degree relative with insomnia (46%) than good sleepers were (33%). Other studies have looked at how common stress-related insomnia in pairs of siblings. The conclusion was that a predisposition to stress-related insomni when a first-degree relative had that kind of insomnia. It also showed that people without this kind of insomnia were more likely to have relatives without it. By showing both sides of the question to some degree of confidence, the researchers showed evidence of an inherited susceptibility to insomnia
An extremely rare and dangerous sleep disorder is fatal familial insomnia. This is a prion disease and as the name implies genetic. The subject usually develops severe insomnia in their 30s and progresses to brain degradation and death.
Recent analysis suggests that observable symptoms of insomnia manifest when people are awake may be related to the source of the insomnia. Insomnia that can be traced to a mental disorder, as well as unknown-origin ‘idiopathic insomnia’, results more often in daytime mood disturbances, while psychophysiological insomnia is more often associated with poor sleep hygiene and tension and low daytime fatigue. Paradoxical insomnia, often called sleep state misrepresentation, resulted in little daytime impairment, while mental health related insomnia typically have high daytime impairment.
Older people have much greater rates of insomnia. This used to be thought normal, but after much arguing and detailed research, the consensus is now that very healthy seniors are not doomed to poor sleep and that insomnia is not an inevitable consequence of age. The fact is that older people have more ailments – diagnosed and undiagnosed, blatant and subtle – than young people and these may affect in myriad ways tendencies to insomnia.
Nina Vujovic of Harvard University posits four basic “ways to mess with sleep.”
These messes include insomnia, hypersomnia, and unrefreshing sleep.
As a practical matter, brain injuries more often result in hypersomnia than insomnia and the unusual circumstances Vujovic mentions are indeed uncommon and rarely experienced by most people, with the exception of pain, which does often cause poor sleep.
Caffeine is the most commonly used stimulant. It blocks adenosine, which makes us sleepy. People use caffeine to stay awake and increase alertness during the day, but of course it makes it tough to fall asleep sometimes.
That is a very broad statement, and tolerance for caffeine varies greatly from person to person depending on brain chemistry and history of consumption.
Some people feel an effect from caffeine but it does not stop them from sleeping well. Indeed, stimulants help some people sleep.
Nicotine is another commonly used stimulant. Widely used through tobacco. The stimulant effect may keep people from falling asleep and the withdrawal symptoms prompt some heavy smokers to wake up earlier than they would otherwise.
Nicotine also shifts some of the sleep architecture from deep and REM sleep toward light sleep. In this way it acts somewhat like alcohol, even though alcohol is a depressant. Alcohol can causesleep maintenance insomnia. Even more than with caffeine, the effect of alcohol varies greatly from person to person and depends on time of consumption, amount consumed, social milieu, and other food and drink consumed. But there is no question alcohol is often a culprit in disturbed sleep and doctors inquire about drinking when investigating sleep disorders. Alcohol also makes snoring and apnea symptoms worse.
Prescription medications and recreational drugs can also disrupt sleep. Look at the warnings or extended labels on medicines and you will often find sleeplessness listed as a potential side effect. Over-the-counter medicines, too. Sometimes you will see both drowsiness and sleeplessness listed. That might sound paradoxical to someone who doesn’t have experience in sleep science, but it is common. Different people react differently. Illegal drugs disrupt sleep, too. They often have powerful effects on the nervous system, which is part of why people use them, but the short-term pleasure sometimes comes with longer-run sleep disruption. Another problem is that these illegal drugs can be adulterated with other materials and the purity and therefore dosages can vary greatly.
The Centers for Disease Control has a metric called the Health-Related Quality of Life (HRQOL) The concept of Quality of Life was developed by psychologists and public health professionals as a “broad multidimensional concept that usually includes subjective evaluations of both positive and negative aspects of life.”
Both common sense and surveys of problem sleepers teach us that poor sleep and the daytime sleepiness that follows it reduces the quality of life.
Direct costs of insomnia include visits to doctors and sleep diagnostic centers and medicines (both prescription and over the counter). Indirect costs include making other illnesses worse and promoting the onset of other diseases,, workplace absenteeism, decreased productivity, industrial and car accidents, and increased alcohol consumption. All told, it adds up to billions, although exactly how much depends on the calculation method and what the analysts are considering part of universe of insomnia consequences.
The National Heart, Blood, and Lung publishes Your Guide to Healthy Sleep which states “chronic sleep loss may affect 70 million Americans, with $16 billion in health care costs and $50 billion in lost productivity”.
The American Insomnia Study undertaken by Harvard Medical School was published in 2011. The study analysts found the average American worker loses 11.3 days in productivity every year. The total cost was estimated at $63.2 billion per year. Another study found insomniacs have twice as many days with restricted activity because of illness. They miss twice as many days of work as good sleepers and even when they are at work, the excessive daytime sleepiness saps productivity
The cost of treating the widespread insomnia would pay for itself just in productivity and absenteeism costs. Every office and break room has a coffeepot. A reaction to insomnia? Maybe. The effects of insomnia, which include poor concentration, decreased memory, and mood changes, make workers less productive and the workplace more contentious. Because insomnia usually does not result directly in absence from the workplace, mostly diminished productivity while at work and a contributing factor to other absence-causing illnesses, it does not get the attention it warrants.
Epidemiologists estimate people with insomnia have 60% higher health costs than good sleepers, although this does not differentiate between insomnia and comorbid conditions and disorders that may be related to insomnia and require separate treatment.
A Quebec study on the subject found that the economic costs of insomnia far exceeded the cost of treatment. You might expect health pros to offer up something so self-serving. But they appear to have done their work. The total estimated cost was 6.6 billion Canadian dollars (2009) with three-quarters of this due to workplace absence and lowered productivity.
A 2004 Australian study estimated financial cost of insomnia 0.8% of gross domestic product.. The authors went further and took a guess at the non-financial cost of suffering at 2.97 billion Australian dollars, or 1.4% of the total disease burden in the country.
Chronic insomnia is technically insomnia lasting over three months, although doctors usually won’t consider the condition chronic until patients have attempted to improve their sleep hygiene, and do not appear to have comorbid conditions causing sleep onset or maintenance problems.
How bad is chronic insomnia? Some find it a mere irritation and others find it debilitating. Some people think they have chronic insomnia, but really don’t. (If you don’t have daytime sleepiness, you don’t formally have insomnia.)
Chronic insomnia poses a challenge for doctors. They are discouraged from prescribing hypnotic drugs for the long term. (Doctors have discretion to do so if they feel it is warranted, but the professional guidelines and FDA labeling generally oppose long-term drug use.) Chronic insomnia has been understudied partly because of its long-term nature. The longest clinical trials of treatments last less than a year, while chronic insomnia can go on for decades, leaving the patient to fend for themselves and find ways to cope.
One strategy some insomniacs employ (either with their doctor’s approval or not) is to rotate sleep aid medications. Spend a few weeks on an over-the-counter antihistamine followed by a few weeks on melatonin followed by a few weeks on a prescription Z-drug. With the occasional drug holiday, people continue like this for years.
Cognitive behavioral therapy (CBT) has been shown time and again to work for insomnia. The main rap against it is the time and expense which compare unfavorably to quick pills. But for chronic insomnia, the calculation works in favor of CBT. The up front investment pays dividends in better sleep and no drug cost in the long run. CBT doesn’t work for everyone, but a good therapist can often help the problem sleeper.
The federal government’s Sleep Disorders Research Plan (2011) says “Chronic insomnia affects nearly one out of five adults,” Sociologists and urban planners coined the term wicked problem to describe difficult situations with conflicting requirements and intractability to solutions. Chronic insomnia could be considered a wicked problem.
Chronic insomnia often sneaks up on people. As we get older, it is common for sleep quality to decline. And the drugs that people take as they get older can interfere with sleep – thyroid preparations, corticosteroids, and blood pressure medications do this. Comorbidities include chronic pain (eg, osteoarthritis, fibromyalgia), gastroesophageal reflux disease (GERD), heart failure, renal disease, diabetes, neurologic problems, and psychiatric disorders.
The pathophysiology of insomnia may be a hyperactivated or hyperaroused state. If this is true, it explains partly the chronic nature. The arousal does not easily diminish and does not go down at night. People describe it as feeling they can’t downshift. Hypnotic drugs induce sleep, but the next day the person feels unrefreshed. People feel the only way to really come down is to take a vacation, and indeed, vacations often “cure” chronic insomnia, at least for a short time. For insomniacs like this, drugs are almost certainly not a good long-term choice. CBT and other behavioral programs are the best method for addressing chronic insomnia.
Biomarkers for stress such as cortisol and ACTH tend to run higher in insomnicas.
This type of dilemma for the patient and doctor – that the insomnia can apparently be stopped only by a vacation — is tough. It is one reason people retire earlier than they otherwise would. Another plausible idea is that chronic insomniacs have “impaired plasticity of the sleep-wake system”. While a normal person or someone with insomnia from another cause might be able to recover from a bad night with extra sleep the next night, the chronic insomiac can’t and accumulates a sleep debt and is stuck with excessive daytime sleepiness.
It’s hard to say how many people have insomnia because (1) different people have different definitions of insomnia and (2) the condition is under-reported and under-diagnosed.
If you read the scientific literature, estimates of the prevalence of insomnia are all over the place. So the problem is not that the lay public doesn’t understand the formal definitions of insomnia; it’s that there are differing data-gathering techniques even among the professionals.
Our assessment: although 30% of the adult population has some bouts or symptoms of insomnia, it is estimated that 10% fit experience excessive daytime sleepiness for at least one month. Further, if you remove other sleep disorders, mental and other physical disorders, and side effects of medicines or substance abuse, the number falls to 6%.
However the NIH Sleep Disorders Research Plan (2011) states “Chronic insomnia affects nearly one out of five adults”.
Some observers feel the prevalence of insomnia is increasing over time, but there is little hard evidence for this allegation. Even if the prevalence is not increasing, the widespread misery it causes is enough to warrant considering insomnia a public health problem. Insomnia reduces the quality of life for millions, causes accidents and workplace absenteeism, and more health care costs.
It is important to remember the formal terminology of epidemiology: Prevalence = (number with disease) / (number in population) Incidence = (number of persons who develop condition ) / (number in population)
There is a positive relationship between incidence and prevalence, but in diseases or illnesses that disappear quickly, it is possible for the incidence rate to be high and the prevalence rate to be low. For insomnia, prevalence is more relevant for chronic insomnia than for acute insomnia.
For more information on insomnia, sleep disorders, classifications, treatment options, and other related subjects, please visit the following Tuck.com pages:
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