Say goodbye to sleepless nights with our comprehensive guide to understanding insomnia. Uncover the root causes behind this frustrating condition and discover treatment

Insomnia

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Syed Intisar Hussain

Overview

Insomnia is a sleep disorder. A person with insomnia has trouble falling asleep or staying asleep. 
&nbsp;

A person with insomnia finds it difficult to stay asleep, fall asleep, or both. Not feeling refreshed after waking up from several hours of sleep, experiencing fatigue, and being unable to function throughout the day are some characteristic signs of insomnia.

While sleeping patterns differ from person to person, adults generally need 7-8 hours of sleep every night. Nearly 6-10% of adults are clinically diagnosed with insomnia disorder, while a third of all adults exhibit some symptoms of insomnia<a href="#accordion">[5]</a>. 
&nbsp;

There are 2 main types of insomnia: 
&nbsp;

<ol>
	<li>
	Acute Insomnia
	</li>
</ol>

Acute or transient insomnia is a brief period where a person has difficulty sleeping. It usually lasts for less than three months, and symptoms may diminish on their own as the person learns to deal with the change or stressful event that led to sleeping problems.

It&rsquo;s usually due to a traumatic experience in life, but it can also occur as a withdrawal symptom of a drug. 
&nbsp;

<ol start="2">
	<li>
	Chronic Insomnia
	</li>
</ol>

Chronic insomnia means the person suffers from long-term sleeping difficulties. They have difficulty falling or staying asleep at least 3 nights a week for 3 months or more. The inability to get enough sleep may be persistent or intermittent, recurring in months-long bursts.

It can be caused by stressful situations, just like acute insomnia, but it can also be linked to persistent nightmares, underlying physical or neurological problems, and medications. 
&nbsp;

<h5>Other Types Of Insomnia</h5>

Acute and chronic insomnia may be further categorized into the following types<a href="#accordion">[6]</a> <a href="#accordion">[7]</a>:

&nbsp;

<ul>
	<li>Primary (Idiopathic) Insomnia</li>
</ul>

This means that sleep issues do not have an obvious cause or any underlying medical condition.

<ul>
	<li>Secondary (Comorbid) Insomnia</li>
</ul>

This occurs when sleep issues are due to a health condition (such as depression or diabetes) or chronic pain. Often, insomnia has a two-way relationship with other health issues. For instance, anxiety contributes to insomnia, and insomnia, in turn, triggers or aggravates <a href="https://merisehat.pk/disease/anxiety">anxiety</a>. Moreover, secondary insomnia may not end even if the underlying condition is resolved.

<ul>
	<li>Sleep-onset Insomnia</li>
</ul>

This refers to having trouble falling asleep even after 20-30 minutes in bed.

<ul>
	<li>Sleep-Maintenance Insomnia</li>
</ul>

Sleep-maintenance insomnia is the inability to sleep through the night. This usually entails waking up at least once during the night and struggling to fall back asleep for at least 20-30 minutes. The fragmented sleep results in decreased sleep quantity and quality, increasing the likelihood of daytime sluggishness or sleepiness.

<ul>
	<li>Early Morning Awakening Insomnia</li>
</ul>

Early morning wakeup insomnia is characterized by waking up much earlier than planned. Some specialists see this as part of sleep maintenance, while others do not.

<ul>
	<li>Mixed Insomnia</li>
</ul>

Even though it is not a standard term, the term &quot;mixed insomnia&quot; can be used to describe people who experience issues with sleep onset, sleep maintenance, and early morning awakening. In general, the broader term insomnia can be thought of as describing mixed insomnia due to the prevalence of overlapping sleeping issues. 
&nbsp;

NOTE: People who suffer from insomnia frequently report that their symptoms change over time, making it challenging to categorize insomnia strictly into the subtypes of onset, maintenance, and early morning awakenings. 
&nbsp;
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Signs and Symptoms

Insomnia can affect both children and adults:

<ul>
	<li>Fatigue</li>
	<li>Attention or memory deficits</li>
	<li>Problems with school, work, or social performance</li>
	<li>Frustration or a bad mood</li>
	<li>Sleepiness during the day</li>
	<li>Decreased motivation</li>
	<li>Increased number of mishaps or accidents</li>
	<li>Behavioral issues, such as aggression and hyperactivity, particularly in children 
	&nbsp;</li>
</ul>

NOTE: Consult your healthcare provider if you are having trouble falling or staying asleep. You should also see a healthcare provider if you have excessive sleepiness or other symptoms. 
&nbsp;

Causes

Some of the most common reasons for chronic insomnia are the following: 
&nbsp;

<ul>
	<li>Stress</li>
</ul>

Every individual is subject to stress in their day-to-day life, whether it&rsquo;s work, school, or family, especially when it&rsquo;s concerning health or finances. A major trauma, like the death of a loved one, job loss, or divorce, can cause insomnia, too. 
&nbsp;

<ul>
	<li>Travel Or Work Schedule</li>
</ul>

The body&rsquo;s circadian rhythm determines its sleep-wake cycle, metabolism, and body temperature. Working a late or early shift and traveling across multiple time zones are some possible causes that disrupt this internal clock and lead to insomnia. 
&nbsp;

<ul>
	<li>Poor Sleep Habits</li>
</ul>

An inconsistent sleep pattern, frequent naps, being active before bed, and an uncomfortable sleeping environment are all examples of poor sleep habits that disrupt the sleep cycle. 
&nbsp;

<ul>
	<li>Eating Late </li>
</ul>

A light snack before bedtime is acceptable, but overeating can cause physical discomfort while lying down. A majority of people have <a href="https://merisehat.pk/disease/heart-burn-58">heartburn</a>, i.e., acid and food travel up from the stomach towards the throat. 
&nbsp;

<ul>
	<li>Mental Health Disorders</li>
</ul>

Insomnia is frequently associated with other mental health disorders. For instance, waking up earlier than intended can be a sign of anxiety. <a href="https://merisehat.pk/disease/ptsd-post-traumatic-stress-disorder">Post-traumatic stress disorder</a> and other anxiety disorders can disrupt sleep as well. 
&nbsp;

<ul>
	<li>Medications</li>
</ul>

Many prescription medications, like antidepressants or blood pressure medications, can interfere with sleep. Even over-the-counter medicines, including pain relievers, allergy medications, and weight-loss supplements, contain caffeine and other stimulants that can cause sleep disruption. 
&nbsp;

<ul>
	<li>Other Medical Conditions</li>
</ul>

Cancer, Heart disease, Diabetes, Chronic pain, <a href="https://merisehat.pk/disease/asthma">Asthma</a>, <a href="https://merisehat.pk/disease/gerd-56">Gastroesophageal Reflux Disease (GERD)</a>, Overactive Thyroid, <a href="https://merisehat.pk/disease/parkinsons-disease">Parkinson&#39;s disease</a>, and <a href="https://merisehat.pk/disease/alzheimers-disease">Alzheimer&#39;s disease</a> are some of the conditions associated with insomnia. 
&nbsp;

<ul>
	<li>Sleep-Related Disorders</li>
</ul>

<a href="https://merisehat.pk/disease/sleep-apnea-91">Sleep apnea</a>, periodic limb movement disorder, delayed sleep phase disorder, and restless leg syndrome make it difficult to sleep. 
&nbsp;

<ul>
	<li>Caffeine, Nicotine, And Alcohol</li>
</ul>

Coffee, tea, cola, and other caffeinated drinks are stimulants. Tobacco products are also stimulants because of the nicotine in them. Therefore, consuming these drinks or smoking in the evening can prevent a person from falling asleep at night.

Similarly, drinking alcohol may cause a person to frequently wake up during the night. 
&nbsp;

<h5>Insomnia And Aging</h5>

Insomnia becomes more common as people get older. This is due to: 
&nbsp;

<ul>
	<li>Changes In Sleep Patterns</li>
</ul>

Older people require the same amount of sleep as younger people. However, their sleep is easily disrupted because of environmental noise. Additionally, their internal clock may change with age, causing them to become tired earlier in the evening and wake up earlier in the morning. 
&nbsp;

<ul>
	<li>Changes In Activity</li>
</ul>

A person may be less active physically or socially. Lack of activity can make getting a good night&#39;s sleep challenging. This is especially because the less active they are, the more likely they are to take a nap during the daytime, thereby disrupting their nighttime sleep.

&nbsp;

<ul>
	<li>Changes In Health</li>
</ul>

Chronic pain from conditions, like back pain, arthritis, depression, or anxiety, can all disrupt sleep. Moreover, problems that increase the need to urinate during the night, such as prostate or bladder problems, can affect sleep. 
&nbsp;

<ul>
	<li>
	More Medications
	</li>
</ul>

Older people tend to use more prescription drugs than younger people, which increases the risk of medication-related insomnia. 
&nbsp;

<h5>Insomnia In Children And Teens</h5>

Children and teenagers may also experience sleep issues. However, this sleep difficulty is natural because their internal clocks are more delayed; they simply want to sleep later at night and wake up later. 
&nbsp;
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There are no tests or guidelines for insomnia screening. 
&nbsp;

Diagnosis

<ul>
	<li>Physical Examination: The doctor may perform a physical exam to look for signs of medical problems that might be causing insomnia. A blood test may be performed to check for thyroid problems or other conditions associated with poor sleep.</li>
	<li>Review The Patient&rsquo;s Sleeping Habits: The physician may ask questions to evaluate the patient&rsquo;s sleep-wake pattern and level of daytime sleepiness. They might also ask the individual to keep a sleep diary for a few weeks.</li>
	<li>Sleep Study: If the cause of the insomnia is unknown, or if the person exhibits symptoms of another sleep disorder, like restless legs syndrome or sleep apnea, then they might be asked to spend the night at a sleep center. Tests during sleep help monitor and record different body activities, such as breathing, brain waves, eye movements, heartbeat, and body movements. 
	&nbsp;</li>
</ul>

Treatment

In addition to lifestyle remedies, the doctor may suggest cognitive behavioral therapy, medications, or both to help patients suffering from insomnia. 
&nbsp;

<h5>Cognitive Behavioral Therapy For Insomnia</h5>

Cognitive behavioral therapy for insomnia (CBT-I) helps the person control or eliminate any negative thoughts and behaviors that keep them awake. It is generally advised as the first line of treatment for people who suffer from insomnia and is usually more efficient than sleep medications.

The individual learns to identify and change the negative or worrying thought patterns that interfere with their ability to fall asleep at night. Moreover, the therapist aims to instill in the person good sleeping habits and also encourage them to avoid behaviors that prevent them from sleeping well.

CBT-I strategies include: 
&nbsp;

<ul>
	<li>Stimulus Control Therapy</li>
</ul>

This is to stop the mind from resisting sleep. For example, the patient is advised to establish a consistent bedtime and wake time, and to leave the bedroom if they can&#39;t fall asleep within 20 minutes, returning only when sleepy. 
&nbsp;

<ul>
	<li>Relaxation Techniques</li>
</ul>

Progressive muscle relaxation, biofeedback, and breathing exercises are recommended before bedtime as they can help the person relax. These techniques effectively slow down the heart rate, elevate mood, and ease muscle tension. As a result, the person can fall asleep quickly and for longer periods. 
&nbsp;

<ul>
	<li>Sleep Restriction</li>
</ul>

This therapy discourages daytime naps. Naps increase the time spent in bed, resulting in partial sleep deprivation or increased fatigue the next night. 
&nbsp;

<ul>
	<li>Remaining Passively Awake</li>
</ul>

This therapy for learned insomnia, also known as paradoxical intention, aims to reduce worry and anxiety about being able to sleep. 
&nbsp;

<ul>
	<li>Light Therapy</li>
</ul>

Light therapy is used to reset the internal clock. 
&nbsp;

<h5>Prescription Medications</h5>

Prescription sleeping pills can help fall asleep, stay asleep, or both. Although doctors generally do not recommend taking prescription sleeping pills for more than a few weeks, several medications are approved for long-term use, like eszopiclone, ramelteon, zaleplon, and zolpidem<a href="#accordion">[8]</a>.

However, prescription sleeping pills can have side effects, such as causing daytime drowsiness and increasing the risk of falling. Also, the patient can become addicted to drugs and may have trouble falling asleep naturally so it&rsquo;s important to discuss it with the doctor first. 
&nbsp;

<h5>Over-the-Counter Sleep Aids</h5>

Nonprescription sleep medications contain antihistamines, which can cause drowsiness, but they are not meant to be used regularly<a href="#accordion">[8]</a>.

NOTE: It&rsquo;s important to consult your doctor before taking these medications because antihistamines can cause side effects, such as daytime sleepiness, cognitive dizziness, confusion, decline, and difficulty urinating, which may be severe for older adults. 
&nbsp;

<h5>Lifestyle And Home Remedies</h5>

<ul>
	<li>Follow a regular sleep schedule. Make sure to go to bed and wake up at the same time every day, including on weekends.</li>
	<li>Stay active. Regular physical activity is crucial for proper sleep. However, any exercise should be done at least a few hours before bedtime.</li>
	<li>Check the medications. Sometimes, insomnia is a side-effect of drugs. Contact a doctor or pharmacist to check if any over-the-counter products or even prescribed medications are contributing to insomnia. </li>
	<li>Avoid naps at all costs. If that&rsquo;s not possible, at least limit them both in terms of frequency and duration as they make it difficult to sleep at night. A nap should not be longer than 30 minutes. Also, it&rsquo;s best to not take a nap after 3 p.m.</li>
	<li>Refrain from caffeine, alcohol, and nicotine. Their effects can last for several hours, which would make it difficult to fall asleep.</li>
	<li>Do not eat large meals before bed. This is to avoid heartburn. Similarly, do not drink too much water or any other beverage before bedtime to avoid getting up frequently to urinate. 
	&nbsp;</li>
</ul>

NOTE: If insomnia is due to pain, talk to your doctor about pain relievers that can control pain while you sleep. 
&nbsp;
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Sleep is as essential for health as a balanced diet and regular exercise. Insomnia, regardless of the cause, can have both mental and physical consequences, including: 
&nbsp;

<ul>
	<li>Decreased productivity at work or school.</li>
	<li>Slower reaction time and, therefore, higher risk of accident, especially while driving.</li>
	<li>Mental health disorders, such as anxiety disorder, depression, and substance abuse.</li>
	<li>Increased risk and severity of long-term diseases, such as hypertension and heart disease. 
	&nbsp;</li>
</ul>

The following factors increase the risk of insomnia: 
&nbsp;

<ul>
	<li>Sex:&nbsp;Women are 1.41 times more likely than males to experience insomnia. Hormonal fluctuations during the menstrual cycle or menopause, for instance, which are responsible for night sweats and hot flashes may cause insomnia<a href="#accordion">[4]</a>.</li>
	<li>Age:&nbsp;Insomnia exacerbates with age due to changes in sleep patterns and health. That&rsquo;s why it mostly affects those above 60<a href="#accordion">[8]</a>.</li>
	<li>Mental health disorder or physical health condition that has an impact on sleep.</li>
	<li>Stress:&nbsp;Significant or prolonged stress can result in chronic insomnia.</li>
	<li>Lack Of Routine:&nbsp;For example, changing shifts at work or spontaneous traveling plans can interrupt the sleep-wake cycle. 
	&nbsp;</li>
</ul>

Good sleep habits, also called sleep hygiene, can help prevent insomnia. They include: 
&nbsp;

<ul>
	<li>Get up at the same time every morning and sleep at the same time every night. It also means avoiding naps throughout the day since they may cause problems sleeping at night.</li>
	<li>Do not use phones or e-Books before going to bed. </li>
	<li>Avoid caffeine, nicotine, and alcohol late in the evening as they can affect the quality of sleep.</li>
	<li>Exercise regularly. However, make sure to time it right. For instance, working out right before bedtime makes it difficult to fall asleep. Exercise at least 3-4 hours before going to bed.</li>
	<li>While a light snack before bedtime is generally recommended for a good night&rsquo;s sleep, avoid eating a large meal late in the day.</li>
	<li>The bedroom environment can be made cozy by keeping it dark, quiet, and just the right temperature. If outside light is an issue (e.g., from a streetlamp), wear a sleeping mask. If it&rsquo;s a noise that&rsquo;s disrupting sleep, use a fan, earplugs, or a white noise machine to avoid it.</li>
	<li>Establish a routine for relaxing before going to bed. This can be taking a bath, listening to music, reading a book, massage, or praying. This is especially helpful in case of sleep-onset insomnia. </li>
	<li>Forcing oneself to sleep is not a good option. Read in another room until the feeling of exhaustion settles in, then go to bed. Don&#39;t go to bed too soon.</li>
	<li>The bed is meant for just sleeping; no work, no food. Also, sleep as much as needed to feel relaxed, then get out of bed.</li>
	<li>Create a to-do list before going to bed to avoid fretting about things. 
	&nbsp;</li>
</ul>

A comprehensive meta-analysis found that yoga improved women&#39;s sleep quality when compared to the control group using the Pittsburgh Sleep Quality Index. 
&nbsp;

In terms of addressing sleep issues, this systematic review and meta-analysis showed that yoga intervention in women could be beneficial in comparison to non-active control settings.

The moderator analyses revealed that participants in the non-peri/postmenopausal subgroup and those without breast cancer were linked to greater advantages, with a direct linkage between total class time as well as sleep quality among other relevant advantages. 
&nbsp;

Key Points

<ul>
	<li>Insomnia is a sleep disorder. A person with insomnia has trouble falling asleep or staying asleep.</li>
	<li>Consult a doctor to find out the source of the sleep disturbance and how to manage it.</li>
	<li>Insomnia itself can be a disease, or it might be a symptom of other diseases. 
	&nbsp;</li>
</ul>

[1] Stoller MK. Economic effects of insomnia. Clin Ther Int Peer-Reviewed J Drug Ther. 1994.

[2] Silvestri R, Aricò I. Sleep disorders in pregnancy. Sleep Sci. 2019;12(3):232.

[3] Bjorøy I, Jørgensen VA, Pallesen S, Bjorvatn B. The prevalence of insomnia subtypes in relation to demographic characteristics, anxiety, depression, alcohol consumption and use of hypnotics. Front Psychol. 2020;11:527.

[4] Wang W-L, Chen K-H, Pan Y-C, Yang S-N, Chan Y-Y. The effect of yoga on sleep quality and insomnia in women with sleep problems: a systematic review and meta-analysis. BMC Psychiatry. 2020;20:1–19.

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