What is insomnia?
Insomnia can be defined as someone experiencing difficulty falling asleep, difficulty maintaining sleep throughout the night or waking up too early in the morning. It can last for only a few days, a couple of weeks or if chronic, for months at a time.
Approximately 15-20% of the population experience what is categorized as transient or short term insomnia. For those afflicted by transient insomnia, symptoms last only for a few days. Short term insomnia can last for several weeks but typically no more than a 3 month span of time. Both transient and short term insomnia can be attributed to specific circumstances such as an acute illness, periods of high stress, travel, a significant life event or a short term medical issue such as surgery or a hospitalization.
Normal sleep and sleeping patterns often resume when the situation or circumstance is resolved. Rebound insomnia, a prime example of transient insomnia, can occur following sleep aid cessation. Lasting for one to two nights, rebound insomnia is the brain reacting to not having sleep aids (either herbal or over the counter) and is “resetting” the sleep pattern without the use of supplemental substances.
Chronic insomnia occurs in about 10% of the population and is a more severe form of insomnia. Insomnia is considered chronic when it occurs at least 3 times a week and lasts for a minimum of 3 months or more. Chronic insomnia may also have a genetic component; recent research suggests that some genes are found in association with the presentation of chronic insomnia in patients.
The most frequent symptoms of insomnia can include tiredness, fatigue, daytime sleepiness and low energy. Other common symptoms of insomnia include:
- Trouble with memory, concentration or the ability to focus
- Poor work or school performance
- Irritability or shifts in mood
- Impulsive or aggressive behaviors
- Loss of motivation
- Growing concern or frustration about sleep
- Errors or accidents
- Lack of balance or coordination
Health risks of insomnia
There are a myriad of health risks associated with insomnia as a result of repeated and disrupted sleeping patterns. Some examples include:
- Cardiovascular disease, heart attack and stroke
- Anxiety and depression
- Alcohol abuse
Insomnia also negatively impacts decision-making and reaction times, increasing the risk of accidents. People experiencing insomnia are 2.8 more likely to die in a car crash.
What causes insomnia?
Insomnia can affect anyone at anytime throughout their lives. Approximately 33% of adults and 20-40% of children and teenagers experience periods of insomnia intermittently. Women typically have higher occurrences of insomnia as do adults over the age of 65. Insomnia is most often linked to another issue or problem that a person is experiencing. Determining the related issue can be beneficial to which course of treatment can provide the best outcome.
There are a wide variety of sources that attribute to a person developing or experiencing insomnia whether short term or chronic.
Causes can vary from person to person. Transient and short term insomnia is often a result of particular situations or circumstances that can disrupt normal day to day living creating a stressful environment. Once the situation is resolved, often the insomnia associated is also resolved.
Chronic insomnia may develop from a short term period of insomnia or develop over time due to a possible genetic connection. There are however other determining factors thought to be involved as well making deciphering exact causes difficult. In general, the occurrence of insomnia is thought to be influenced by a combination of different factors. Categorized as the “3 P’s of insomnia” such factors include predisposing factors, precipitating factors and perpetuating factors.
Predisposing factors can be identified as a genetic composition resulting in someone being prone to having insomnia. It is thought that those affected have a lower threshold for waking meaning they have a greater tendency to experience arousals while asleep and awaken easily. Such a factor can be challenging to correct. In addition, predisposing factors can include chronic health conditions that are pre-existing can therefore increase the risk of someone experiencing insomnia. Some chronic health conditions include:
- Chronic pain
- Sleep disordered breathing
- Restless Legs Syndrome
- Kidney disease or bladder dysfunction
- Chronic mood disorders (Depression and/or anxiety)
- Gastrointestinal Reflux Disease (GERD)
- Neurological Disorders (Alzheimer’s Disease, Parkinson’s Disease)
- Lung disease
- Cardiovascular disease
If possible, trying to treat some pre-existing factors can improve the level of severity of insomnia experienced.
Precipitating factors are categorized as “triggers” that initiate sleep difficulties or exacerbate sleep difficulties within a person’s life. Such factors can include:
- Acute illness
- Stressful life events
- Heightened emotional experiences (either positive or negative)
While precipitating factors cannot be completely eradicated, use of behavioral and cognitive therapies can work to lessen the magnitude of the triggers.
Perpetuating factors, as the name suggests, includes repetitive behaviors or situations that continually propel the occurrence of insomnia. Example of perpetuating factors include inadequate sleep hygiene, environmental factors, and persistent, negative ideas about insomnia itself as well as its overall effects. Out of all three of the “3 Ps”, perpetuating factors are most likely to respond positively to treatments and interventions. Common treatments include cognitive and behavioral therapy, medications and alterations to inappropriate sleep hygiene routines.
In addition to the “3 Ps”, certain medications or classes of medications can also increase the risk of insomnia occurring in some people as a possible side effect. These include:
- Antidepressants-Selective Serotonin Reuptake Inhibitors (Zoloft, Paxil, Prozac, Cymbalta, and Lexapro)
- Stimulants (Caffeine, amphetamines, and ephedrines-includes Adderall)
- Decongestants (Pseudoephedrine and phenylephrine)
- Narcotic analgesics (Oxycodone, Oxycontin, Percocet and Codeine)
- Cardiovascular (?-Blockers, Diuretics, and lipid lowering medications)
- Pulmonary (Theophylline and albuterol)
Furthermore, consistent use of caffeine, nicotine or alcohol can also lead to insomnia or worsen insomnia that is already occurring.
Insomnia is linked to a number of other health disorders, from heart disease to arthritis. People experiencing insomnia have a significantly increased risk of developing depressive disorder. Chronic pain and increased pain sensitivity are also linked to insomnia.
Some chronic health conditions that can increase the risk of insomnia:
Diagnosis and treatment of Insomnia
Due to the complexity of precipitating components associated with insomnia, diagnosing it can be challenging. To start, a physician would require a detailed health history. Treating underlying health conditions may also help to decrease the symptoms of insomnia. In addition they may ask pertinent questions about sleeping habits and patterns in particular. Such questions may include(but not limited to):
- How long does it take for you to fall asleep at night? Do you feel it is longer than 30 minutes?
- Do you wake up during the night and if so how many times?
- Do you have difficulties returning to sleep after waking during the night?
- Do you repeatedly wake up earlier than required?
- Do you experience daytime symptoms like fatigue, sleepiness or a decrease in energy levels?
- Do you have any underlying medical conditions that would interfere with regular sleep?
- What medications (both prescriptions and non-prescription) are you taking and when during the day are they taken?
In addition to specific questions, a physician often will request a sleep journal or sleep diary to be kept by the patient. A sleep journal is typically a 2-3 week log keeping detailed information on sleeping habits, sleeping times, sleep environment, and subjective sleep quality. All of the information gathered helps provide a more comprehensive view of what kind of insomnia is being experienced. Therefore by determining the kind of insomnia, the best course of treatment can be explored for relief. Treatments often feature changes in behavior surrounding sleeping habits, overall lifestyle changes and in some instances short term medication use. A combination may also be useful depending on the severity of insomnia being experienced.
Behavioral Treatment for Insomnia
Behavioral treatments include alterations in behaviors surrounding sleep; changing internal thoughts/impressions of sleep, changing the sleep environment or activities leading to sleep and overall sleep routines. All treatments are rooted in the person developing new associations with sleep as a means to mitigate insomnia.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
Cognitive Behavioral Therapy for Insomnia is a form of talk therapy addressing the recurring thoughts and behavioral patterns involved in maintaining sleeplessness. It is most commonly used for those suffering from chronic insomnia. Over time, those with chronic insomnia develop severe, negative responses or associations to sleep and CBT-I works to undo those negative thoughts by developing healthy associations. As with traditional talk therapy, there is a time commitment required. Typically CBT-I involves 6-10 hour long sessions over a time span of 6-12 weeks in length. Treatment typically includes the use of stimulus control, sleep restriction, relaxation training and biofeedback, cognitive control as well as sleep hygiene training.
An alternative to CBT-I is Brief Behavioral Treatment for Insomnia or BBT-I which is a condensed version of CBT-I using similar techniques of stimulus control and sleep restriction. BBT-I is shorter in duration (usually over 4 week time span) and can be delivered by a wider range of medical clinicians trained in health coaching. As with CBT-I there is a time commitment involved.
Stimulus control involves establishing a positive association between sleep and the bed. For many suffering from chronic insomnia, frustration can often become associated with bedtime and sleeping due to countless, recurring nights of lying awake or tossing and turning without sleep. Overtime, the response to bedtime can become overwhelmingly negative perpetuating insomnia. The use of stimulus control works to undo the negative response to bedtime and sleep. This method requires limiting the use of the bed for only sleep and intimacy. Reading, TV watching, electronic device usage or anything else not associated with sleep or sex should not be done while in bed. Stimulus control also requires going to bed only when sleepy. If after 20-30 minutes sleep is not obtained, it is suggested to leave the bed and do something else relaxing and return to bed only when sleepy again. Over time, the bed is associated with sleepiness and sleep.
Sleep restriction therapy
Sleep restriction is as the name implies, is a restriction on the amount of time spent in bed each night. A specific amount of sleep time is utilized to create a situation where sleep can be obtained without the struggles of trying to fall asleep. The initial restriction or limitation is the amount of sleep actually acquired by someone suffering with insomnia. If the person is in bed for 7 hours, but really only sleeps 4 hours due to the first 3 hours lying awake, then the sleep restriction is set at 4 hours. In the beginning, some sleep deprivation occurs but the deprivation is actually a benefit; falling asleep will become easier and faster. The goal with sleep restriction is to end with the amount of sleep needed without decreasing the quality of sleep obtained.
Relaxation training and biofeedback
Relaxation training includes methods such as meditation and learning to relax the mind and body together. It often involves systematic muscle relaxation and deep breathing exercises.
Biofeedback works with a device that use sound, imagery or a gauge to relay certain aspects of the body with respect to their level of relaxation. Such indicators can include blood pressure, heart rate, body temperature and muscle tension. A person can then be taught how to alter the levels as a means to induce sleep. It can be difficult to learn the process and does require time and the ability to focus and concentrate for results.
Cognitive control is the use of psychotherapy to change negative thoughts and attitudes with regard to sleep. As with other treatments for insomnia, cognitive control can be time consuming and requires repeated sessions for the best outcomes. Often psychotherapists work to overcome difficulties with use of imagery, or setting specific times for negative thoughts to occur as a means to curb such thoughts near sleep onset.
Sleep hygiene training
Sleep hygiene refers to the practices and routines surrounding sleeping. Good sleep hygiene includes caffeine limitations close to bedtime, using the bed for sleep and intimacy only, resolving to not use electronics in bed or close to sleep onset and restriction of daytime sleep in the form of long, extensive naps.
Medicines for insomnia
Some physicians may prescribe medication as a treatment for insomnia. In most instances, medications used to treat insomnia are for short term use and are not intended to be taken for long periods of time. Most short term medications are only used for 1-4 weeks at a time. Some are used independently of other treatments and some are used in conjunction with alternative methods of treatment. Utilizing medication as a form of treatment is left to the discretion of the physician and the patient. As with any treatment regime there are benefits and risks involved. Discussing which option is best for the kind of insomnia being experienced is key for optimal results.
Prescription Insomnia Medications
- Diazepam (Valium)
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
- Alprazolam (Xanax)
Benzodiazepine receptor agonists
- Zolpidem tartrate (Ambien)
- Zaleplon (Sonata)
- Eszopiclone (Lunesta)
- Melatonin receptor agonists
- Amelteon (Rozerem)
- Agomelatine (Valdoxan, Melitor, Thymanax)
- Tasimelteon (Hetlioz)
- Orexin receptor antagonists
Over-the-counter (OTC) sleep aids
- Diphenhydramine (Benadryl)
- Doxylamine (Unisom)
- Triprolidine (Actidil, Myidil, Actifed)