What is Insomnia?

Everyone has an occasional sleepless night. Most people at some point in life report having problems falling asleep or staying asleep through the night. A person may have sleep problems for many reasons. Causes include poor sleep environment, drinking caffeinated or alcoholic beverages, facing stress, or taking certain medications. Sleep problems often occur when a person has a physical problem, such as pain or heart disease, or a mental disorder, such as depression or anxiety.

A sleep problem that occurs at least three days a week for three months or longer is called chronic insomnia. Sleep problems that do not last this long are called acute insomnia. Chronic and acute insomnia can be treated, but acute insomnia sometimes gets better without treatment.

Insomnia means a person spends enough time in bed, but can’t sleep. In contrast, sleep deprivation means a person has no trouble sleeping, but spends too little time in bed. Sleep deprivation is not a sleep disorder.

Insomnia is the most common sleep complaint in the United States. About 10% of adults have chronic insomnia.

The American Psychiatric Association includes insomnia among 10 kinds of sleep disorder. The others are hypersomnolence disorder, narcolepsy, breathing-related sleep disorders (sleep apnea), circadian rhythm sleep-wake disorders, non-rapid eye movement (NREM) sleep arousal disorders, nightmare disorder, rapid eye movement (REM) sleep behavior disorder, restless legs syndrome, and substance/medication-induced sleep disorder.

Signs and Symptoms

Acute insomnia generally lasts from several weeks up to three months. It often results from situations such as stress at home or at work, the loss of a loved one, a change in sleep environment, or short-term physical discomfort.

Chronic insomnia lasts three months or longer. In chronic insomnia, sleep problems sometimes come and go, with several days of good sleep followed by a stretch of bad sleep.

People with acute or chronic insomnia face distress or problems with daily functioning (such as work, driving, social activities, and school). The insomnia impairs quality of life.

People with insomnia have one or more of these problems:

Trouble falling asleep—“tired but wired”
Trouble staying asleep or waking up multiple times during the night
Waking up too early in the morning and not being able to go back to sleep
Waking up in the morning feeling unrefreshed

During the day, insomnia may impair a person’s life in these ways:

Increased sleepiness
Low energy, tiredness, or fatigue
Increased anxiety or worry
Mood disturbance such as irritability, sadness, and shortened temper
Feeling impulsive or aggressive
Problems focusing and concentrating
Problems remembering things
Problems making decisions

Risk Factors

Insomnia affects more women than men. It can occur at any age, but older adults are more likely to have insomnia than younger people.

Acute insomnia is a risk factor for chronic insomnia.

Insomnia is linked to several factors, including lifestyle, behavioral health or medical conditions, and medications. In some cases, it is unclear if insomnia is related to any risk factor.

Lifestyle Risk Factors

Many lifestyle factors can play a role in insomnia, including:

Positive stress, such as planning for a wedding or a trip
Emotional distress, such as divorce or the death of a loved one
An uncomfortable sleep environment (bedroom or place where the person sleeps)
Large temperatures changes in the environment
Sleep schedules that do not match up with the person’s natural wake-sleep cycle, caused by factors such as jet lag (time change when traveling) or working night shifts
Worrying about having sleep problems
Drinking large amounts of caffeine or alcohol before bedtime
Excessive napping in the afternoon or evening
Spending an excessive amount of time in bed
Not getting up at the same time each morning
Having an inactive lifestyle

Behavioral Health and Medical Factors

Some researchers think insomnia is a problem when the brain is unable to stop being awake. Your brain has a sleep cycle and a wake cycle—when one is turned on, the other is turned off. Insomnia can be a problem with either cycle.

Insomnia often occurs along with physical and behavioral health conditions. Some disorders linked to insomnia include:

Mental disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD)
Use of substances such as caffeine, over-the-counter stimulant medications (including cough and cold remedies containing dextromethorphan), tobacco and other nicotine products, alcohol, and sedatives
Illnesses that cause ongoing pain, such as arthritis and headache disorders
Illnesses that make it hard to breathe, such as asthma and heart failure
An overactive thyroid
Gastrointestinal disorders, such as heartburn
Stroke
Neurodevelopmental and neurological problems, such as autism, Alzheimer’s disease, and Parkinson’s disease
Other sleep disorders, such as restless legs syndrome and sleep-related breathing problems
Circadian rhythm disorders (timing of internal sleep clock)
Menopause and hot flashes

Medication as a Factor

Medications may play a role in sleep problems. This is called a medication-induced sleep disorder. Stimulant medications keep a person from sleeping. Sedative medications make a person feel sleepy. If taken at the wrong time of day, medications may contribute to daytime sleepiness or trouble sleeping at night. For example, certain asthma medicines, allergy medications, and cold medicines may be stimulating and lead to insomnia. Beta blockers, which are used to treat heart disease, are also linked to insomnia. Some medications for treating mental disorders, such as antidepressants and Ritalin for attention deficit hyperactivity disorder (ADHD), may lead to insomnia in some people.

Evidence-based Treatments

When a sleep problem lasts for just a few days, treatment may be unnecessary. For example, after traveling to another time zone, it may be difficult to sleep due to jet lag and a new sleep environment. In this case, the person’s body likely will return naturally to a normal sleep-wake schedule.

In other cases, it is important to treat insomnia, especially when lack of sleep causes ongoing problems in daily life.

Insomnia often is linked to medical illnesses, mood disorders, anxiety disorders, and substance use problems. These should be treated at the same time as insomnia disorder. Insomnia can worsen the symptoms of other medical or mental disorders. Similarly, the other disorders may worsen the insomnia. The treatment plan should consider each person’s needs and choices. A person should consult a healthcare professional when choosing the right treatment and consider their own gender, race, ethnicity, language, and culture.

Assessment

Most clinicians start treatment by asking about health and lifestyle factors that might be related to sleep problems. These assessments can help a clinician better understand a person’s sleep problem.

A clinician determines sleep history by asking questions such as: What time to you go to bed? How long does it take you to fall asleep? How often do you wake up at night? What time to you get up in the morning (on weekdays and on weekends)? The clinician may ask the person to track their sleep patterns using a sleep log or sleep diary (PDF | 51 KB).

Activigraphy is a device worn on the wrist that measures movement. This provides an estimate of how long you sleep at night and how often you wake up at night. The device is generally worn for at least seven days, and often 14 days or longer.

A clinician performs a complete physical exam to rule out medical problems that might cause insomnia. A blood test can check for thyroid problems or other disorders that can cause sleep problems. A physical exam may reveal whether insomnia is an early warning sign of another medical problem.

A person may undergo an overnight sleep study, or polysomnography. The person sleeps overnight in a sleep study lab. There, a machine can monitor stages of sleep. But sleep studies are increasingly done in a person’s own home. The main goal is to identify sleep-related breathing difficulties. In general, a sleep study is used for insomnia only if there may be another sleep disorder.

Based on the assessment, a clinician is likely to suggest a course of treatment. This might include sleep hygiene changes, psychotherapy, medication, or a combination.

Sleep Hygiene

Sleep hygiene, sometimes called lifestyle changes, can help promote sleep. These changes can make it easier to fall asleep and stay asleep. A person can do them without seeking professional help. Here are examples of sleep hygiene:

Adopting good bedtime habits, including a routine with relaxing activities before bed, such as reading, listening to music, or taking a bath
Avoiding heavy meals or drinking a lot of fluids before bedtime
Up to eight hours before bedtime, avoiding substances that make sleeping difficult, including caffeine, tobacco, and stimulants such as energy drinks or diet pills
Avoiding, if possible, certain over-the-counter and prescription medicines, such as some cold and allergy medicines that contain pseudoephedrine
Avoiding alcohol before bedtime, which increases the likelihood of waking up often during the night
Creating a sleep-friendly environment by reducing light in the bedroom from windows and digital devices that produce
Limiting distractions, such as a TV, tablet, smartphone, or computer
Keeping the room temperature cool and comfortable
Going to bed when feeling sleepy, but getting up at the same time each day

Psychotherapy

There are many forms of psychotherapy, sometimes called “talk therapy,” that are effective for insomnia. Visit Psychotherapies at the National Institute of Mental Health (NIMH) to learn about psychotherapies.

Cognitive Behavioral Therapy for Insomnia (CBT-I) is often the initial treatment for chronic insomnia. It targets difficulty falling sleep, maintaining sleep, or both. It is sometimes combined with other psychotherapy approaches. CBT-I usually lasts for four to 10 weeks. Up to 70% of people who complete CBT-I improve, and nearly 40% have average or good sleep after treatment. For people with insomnia who have another medical or mental disorder such as depression or chronic pain, CBT-I improves overall health and may reduce thoughts of suicide.

Relaxation training or progressive muscle relaxationteaches a person to tense and relax muscles in different parts of the body. This helps calm the body and promote falling sleep.

Stimulus control, sometimes called reconditioning, limits the type of activities allowed in the bedroom. The bed is linked to sleep and sex only, not other activities such as eating, working, watching TV, or scanning the Internet.

Sleep restriction involves a strict schedule of bedtimes and wake times, and limits time in bed to sleep time.

Medications

Many prescription medicines are used to treat insomnia. Some are meant for short-term use. Others may be used for a longer length of time.

Non-pharmacological treatments such as therapy are the first line interventions; however, if pharmacological treatment is needed, it is best to consult a professional for an individualized care plan, as some medications can be habit forming.

It is important to consider the effectiveness and side effects of medications. Some insomnia medicines may lose their effectiveness over time.

Some over-the-counter products claim to treat insomnia. For example, medicines that contain antihistamines, typically used to treat allergies, are often sold as sleep aids. Antihistamines are likely to make a person drowsy, but there may be other side effects.

Other over-the-counter products advertised as sleep aids include natural ingredients such as melatonin, L-tryptophan, and valerian. The Food and Drug Administration does not regulate “natural” products, so the dose and purity of these products can vary.

Complementary Therapies and Activities

Complementary therapies and activities can help people improve their overall well-being, and are meant to be used along with evidence-based treatments. For more information on natural products or mind-body practices, see the National Center for Complementary and Integrative Health.

Exercise or physical activity may contribute to healthy sleep.

Hypnotherapy is sometimes used to make cognitive-behavioral therapy and relaxation techniques more effective.

Melatonin in small doses may help promote sleep in some people. It seems to be relatively safe for short-term use for adults. There is no data on safety or effectiveness for adolescents.

Relaxation techniques done independently, without clinician supervision, can be helpful. A person can use books and self-paced audio or video resources to learn relaxation techniques.

Yoga and massage therapy have been shown in some Several other studies have also reported that mindfulness-based stress reduction improved sleep, but the people who participated in these studies had other health problems, such as cancer.studies of postmenopausal women to be helpful for insomnia.

Studies of melatonin in children with sleep problems suggest that it may be helpful, both in generally healthy children and in those with conditions such as autism or attention-deficit hyperactivity disorder. However, both the number of studies and the number of children who participated in the studies are small, and all of the studies tested melatonin only for short periods of time.

Melatonin supplements appear to be relatively safe for short-term use, although the use of melatonin was linked to bad moods in elderly people (most of whom had dementia) in one study.

The long-term safety of melatonin supplements has not been established.

Studies of L-tryptophan supplements as an insomnia treatment have had inconsistent results, and the effects of 5-HTP supplements on insomnia have not been established.

The use of L-tryptophan supplements may be linked to eosinophilia-myalgia syndrome (EMS), a complex, potentially fatal disorder with multiple symptoms including severe muscle pain. It is uncertain whether the risk of EMS associated with L-tryptophan supplements is due to impurities in L-tryptophan preparations or to L-tryptophan itself.

Mindfulness-based stress reduction is a type of meditation that can help with sleep.

Other relaxation techniques involve breathing exercises and guided imagery.

Studies of aromatherapy and homeopathic medicines have not shown effects on insomnia. Likewise, teas and supplements with chamomile, valerian (an herb said to have sedative properties), hops, lemon balm, passionflower, and kavahave not been shown to help with insomnia. Kava supplements have been linked to a risk of severe liver damage.

Recovery and Social Support Services and Activities

Recovery is a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential. One of the hallmarks of effective treatment is that it is durable. Good sleep is an important part of good health and recovery. Treating insomnia may help with recovery and improve health. Recovery from insomnia is likely through a combination of treatment and managing the symptoms.

Self-help and support groups can provide people with the knowledge and support to make treatment decisions that work for them.

Here are resources for people with insomnia and other sleep problems:

Sources: https://www.samhsa.gov/treatment/mental-disorders/insomnia-disorders