INSOMNIA

Overview

Insomnia is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep. You may still feel tired when you wake up. Insomnia can lead to low energy level and mood and also affect your overall health, work performance and quality of life.

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How much sleep is enough varies from person to person, but most adults need seven to eight hours a night.

At some point, many adults experience short-term (acute) insomnia, which lasts for days or weeks. It's usually the result of stress or a traumatic event. But some people have long-term (chronic) insomnia that lasts for a month or more. Insomnia may be the primary problem, or it may be associated with other medical conditions or medications.

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Symptoms

Insomnia symptoms may include:

• Difficulty falling asleep at night

• Waking up during the night

• Waking up too early

• Not feeling well-rested after a night's sleep

• Daytime tiredness or sleepiness

• Irritability, depression or anxiety

• Difficulty paying attention, focusing on tasks or remembering

• Increased risk for errors or accidents

• Ongoing worries about sleep

 

Causes

Insomnia may be the primary problem, or it may be associated with other conditions.

Chronic insomnia is usually a result of stress, life events or habits that disrupt sleep. Treating the underlying cause can resolve the insomnia, but sometimes it can last for years.

 

Common causes of chronic insomnia include:

• Stress. Concerns about work, school, health, finances or family can keep your mind active at night, making it difficult to sleep. Stressful life events or trauma — such as the death or illness of a loved one, divorce, or a job loss — also may lead to insomnia.

• Travel or work schedule. Your circadian rhythms act as an internal clock, guiding such things as your sleep-wake cycle, metabolism and body temperature. Disrupting your body's circadian rhythms can lead to insomnia. Causes include jet lag from traveling across multiple time zones, working a late or early shift, or frequently changing shifts.

• Poor sleep habits. Poor sleep habits include an irregular bedtime schedule, naps, stimulating activities before bed, an uncomfortable sleep environment, and using your bed for work, eating or watching TV. Computers, TVs, video games, smartphones or other screens just before bed can interfere with your sleep cycle.

• Eating too much late in the evening. Having a light snack before bedtime is OK, but eating too much may cause you to feel physically uncomfortable while lying down. Many people also experience heartburn, a backflow of acid and food from the stomach into the esophagus after eating, which may keep you awake.

 

Chronic insomnia may also be associated with medical conditions or the use of certain drugs. Treating the medical condition may help improve sleep, but the insomnia may persist after the medical condition improves.

 

Additional common causes of insomnia include:

• Mental health disorders. Anxiety disorders, such as post-traumatic stress disorder, may disrupt your sleep. Awakening too early can be a sign of depression. Insomnia often occurs with other mental health disorders as well.

• Medications. Many prescription drugs can interfere with sleep, such as certain antidepressants and medications for asthma or blood pressure. Many over-the-counter medications — such as some pain medications, allergy and cold medications, and weight-loss products — contain caffeine and other stimulants that can disrupt sleep.

• Medical conditions. Examples of conditions linked with insomnia include chronic pain, cancer, diabetes, heart disease, asthma, gastroesophageal reflux disease (GERD), overactive thyroid, Parkinson's disease and Alzheimer's disease.

• Sleep-related disorders. Sleep apnea causes you to stop breathing periodically throughout the night, interrupting your sleep. Restless legs syndrome causes unpleasant sensations in your legs and an almost irresistible desire to move them, which may prevent you from falling asleep.

• Caffeine, nicotine and alcohol. Coffee, tea, cola and other caffeinated drinks are stimulants. Drinking them in the late afternoon or evening can keep you from falling asleep at night. Nicotine in tobacco products is another stimulant that can interfere with sleep. Alcohol may help you fall asleep, but it prevents deeper stages of sleep and often causes awakening in the middle of the night.

 

Risk factors

Nearly everyone has an occasional sleepless night. But your risk of insomnia is greater if:

• You're a woman. Hormonal shifts during the menstrual cycle and in menopause may play a role. During menopause, night sweats and hot flashes often disrupt sleep. Insomnia is also common with pregnancy.

• You're over age 60. Because of changes in sleep patterns and health, insomnia increases with age.

• You have a mental health disorder or physical health condition. Many issues that impact your mental or physical health can disrupt sleep.

• You're under a lot of stress. Stressful times and events can cause temporary insomnia. And major or long-lasting stress can lead to chronic insomnia.

• You don't have a regular schedule. For example, changing shifts at work or traveling can disrupt your sleep-wake cycle.

 

Complications

Insomnia can affect you both mentally and physically.

Complications of insomnia may include:

• Lower performance on the job or at school

• Slowed reaction time while driving and a higher risk of accidents

• Mental health disorders, such as depression, an anxiety disorder or substance abuse

• Increased risk and severity of long-term diseases or conditions, such as high blood pressure and heart disease

 

Prevention

Healthy sleep habits, good sleep hygiene can help prevent insomnia and promote sound sleep:

• Keep your bedtime and wake time consistent from day to day, including weekends.

• Stay active — regular activity helps promote a good night's sleep.

• Check your medications to see if they may contribute to insomnia.

• Avoid or limit naps.

• Avoid or limit caffeine and alcohol, and don't use nicotine.

• Avoid large meals and beverages before bedtime.

• Make your bedroom comfortable for sleep and only use it for sex or sleep.

• Create a relaxing bedtime ritual, such as taking a warm bath, reading or listening to soft music.

 

Diagnosis

Your healthcare provider will conduct a physical exam, review your sleep habits and in some cases, order a sleep study to evaluate your insomnia and formulate the right treatment plan for you.

 

Treatment

The foundation for treating insomnia includes healthy sleep habits, cognitive behavioral therapy, and medications.

 

Cognitive behavioral therapy for insomnia

Cognitive behavioral therapy for insomnia (CBT-I) can help you control or eliminate negative thoughts and actions that keep you awake and is generally recommended as the first line of treatment for people with insomnia. Typically, CBT-I is equally or more effective than sleep medications.

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The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep. It can help you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating the cycle that can develop where you worry so much about getting to sleep that you can't fall asleep.

The behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.

 

Strategies include, for example:

• Stimulus control therapy. This method helps remove factors that condition your mind to resist sleep. For example, you might be coached to set a consistent bedtime and wake time and avoid naps, use the bed only for sleep and sex, and leave the bedroom if you can't go to sleep within 20 minutes, only returning when you're sleepy.

• Relaxation techniques. Progressive muscle relaxation, biofeedback and breathing exercises are ways to reduce anxiety at bedtime. Practicing these techniques can help you control your breathing, heart rate, muscle tension and mood so that you can relax.

• Sleep restriction. This therapy decreases the time you spend in bed and avoids daytime naps, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.

• Remaining passively awake. Also called paradoxical intention, this therapy for learned insomnia is aimed at reducing the worry and anxiety about being able to get to sleep by getting in bed and trying to stay awake rather than expecting to fall asleep.

• Light therapy. If you fall asleep too early and then awaken too early, you can use light to push back your internal clock. You can go outside during times of the year when it's light outside in the evenings, or you can use a light box. Talk to your doctor about recommendations.

Your doctor may recommend other strategies related to your lifestyle and sleep environment to help you develop habits that promote sound sleep and daytime alertness.

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Prescription medications

Prescription sleeping pills can help you get to sleep, stay asleep or both. Doctors generally don't recommend relying on prescription sleeping pills for more than a few weeks, but several medications are approved for long-term use.

Examples include:

• Eszopiclone (Lunesta)

• Ramelteon (Rozerem)

• Zaleplon (Sonata)

• Zolpidem (Ambien, Edluar, Intermezzo, Zolpimist)

Prescription sleeping pills can have side effects, such as causing daytime grogginess and increasing the risk of falling, or they can be habit-forming, so talk to your doctor about these medications and other possible side effects.

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Over-the-counter sleep aids

Some Nonprescription sleep medications contain antihistamines that can make you drowsy, but they're not intended for regular use and may have several other potential side effects. Talk to your doctor about all OTC medications you are taking.

 

Lifestyle and home remedies

The sleep and wake cycle function in an hourglass manner, i.e, under normal circumstances, the more sleep you have at night, the more awake you’ll feel during the day and vice versa. What you do during the day and around bedtime can significantly affect the quality and quantity of sleep you get at night.

• Stick to a sleep schedule. Keep your bedtime and wake time consistent from day to day, including on weekends.

• Stay active. Regular activity helps promote a good night's sleep. Schedule exercise at least a few hours before bedtime and avoid stimulating activities before bedtime.

• Check your medications. If you take medications regularly, check with your doctor to see if they may be contributing to your insomnia. Also check the labels of OTC products to see if they contain caffeine or other stimulants, such as pseudoephedrine.

• Avoid or limit naps. Naps can make it harder to fall asleep at night. If you can't get by without one, try to limit a nap to no more than 30 minutes and don't nap after 3 p.m.

• Avoid or limit caffeine and alcohol and don't use nicotine. All of these can make it harder to sleep, and effects can last for several hours.

• Don't put up with pain. If a painful condition bothers you, talk to your doctor about options for pain relievers that are effective enough to control pain while you're sleeping.

• Avoid large meals and beverages before bed. A light snack is fine and may help avoid heartburn. Drink less liquid before bedtime so that you won't have to urinate as often.

• Make your bedroom comfortable for sleep. Only use your bedroom for sex or sleep. Keep it dark and quiet, at a comfortable temperature. Hide all clocks in your bedroom, including your wristwatch and cellphone, so you don't worry about what time it is.

• Find ways to relax. Try to put your worries and planning aside when you get into bed. A warm bath or a massage before bedtime can help prepare you for sleep. Create a relaxing bedtime ritual, such as taking a hot bath, reading, soft music, breathing exercises, yoga or prayer.

• Avoid trying too hard to sleep. The harder you try, the more awake you'll become. Read in another room until you become very drowsy, then go to bed to sleep. Don't go to bed too early, before you're sleepy.

• Get out of bed when you're not sleeping. Sleep as much as you need to feel rested, and then get out of bed. Don't stay in bed if you're not sleeping.