The core component of Insomnia Disorder is either sleep that is not restful or not enough sleep. These people suffer with difficulty falling asleep, staying asleep, or waking up too early in the morning. Lack of energy and midday sleepiness are the most common results of insomnia. Daytime napping worsens the situation and makes it even harder to fall asleep at night. Lost sleep causes irritability, poor moods, and sometimes symptoms of depression and anxiety. At work and at school, people will notice that their thinking is slowed and their minds feel foggy.
People become frustrated with their sleep problems. They lie awake in bed worrying about being tired the next day, repeatedly checking the clock, and excessively focused on trying to sleep. They imagine the worst possible outcomes about the insomnia and excessively focus on those. People have performance anxiety about their sleep and their ability to remedy the problems with their sleep. This anxiety and these behaviors aggravate the situation and create a cycle of worry that makes the insomnia worse.
Causes and Risk Factors
Age and gender
According to the most narrow definition of the disorder, at least 6% of adults struggle with insomnia, and about 30% deal with some insomnia symptoms. Those hit most frequently include women and the elderly. In women, hormone changes during periods and menopause contribute, while insomnia in older people reflects a natural decline in the sleep-wake cycle.
Sleep-wake cycle disruptions
Anything that disturbs the natural correspondence between the body’s sleep-wake cycle and the daytime and nighttime can contribute to the development of insomnia. A significant culprit in this case is people who work the night shift and must continually fight to sleep during the day and stay awake at night. Work schedules that change from daytime to nighttime and back on a regular basis make the situation even worse. People who live close to the earth’s poles deal with very long days and very long nights during different parts of the year face the unique challenge of keeping a regular sleep schedule in spite of this odd day-night pattern.
Insomnia that occurs by itself (rather than as a symptom of another disorder) often begins with excess energy and alertness during the daytime that translates into problems getting to sleep and staying asleep at night. This extra energy is not just mental; it is measurable in the body’s vital signs as well. These people have faster average heart rates and increased metabolic rates. Their brains are more active and consume higher levels of energy both during sleep and waking hours. Additionally, levels of stress hormones in the body are measurably higher as well in these people.
Long-term medical illnesses
Between 75% and 90% of people with insomnia also struggle with co-occurring medical issues. Acid reflux, chronic pain, neurological disorders, and conditions affecting breathing all negatively affect sleep.
Other sleep disorders
Though insomnia can develop as a standalone sleep disorder, it also frequently appears as a symptom of other sleep disorders. These include movement disorders like Restless Legs Syndrome and breathing disorders such as Obstructive Sleep Apnea.
Anxiety and depression
Roughly 40% of everyone with insomnia has a co-existing mental health condition. When insomnia is the main problem, symptoms of anxiety and depression will often appear as well. In turn, if someone has a full depressive or anxious disorder, insomnia frequently follows, and both need to be treated. Newly developed insomnia can also aggravate and reawaken dormant mood conditions that had previously been under control. For example, it can precipitate depressive or manic episodes in people with a history of Bipolar Disorder.
Diagnosing Insomnia Disorder
The criteria and types
Insomnia Disorder includes decreased or disturbed sleep in at least three nights a week for three or more months at a time. Any part of nighttime rest can be disrupted, and these troubles lead to problems in peoples’ social lives and workplaces. Although difficulty sleeping is based mostly on peoples’ subjective experiences, some time-based guidelines are helpful. People have difficulty falling asleep initially (“sleep onset insomnia”), taking over 30 minutes of lying in bed with the lights off. Others wake up in the middle of the night (“sleep maintenance insomnia”) for at least 30 minutes before going back to sleep. These two are the more common forms of insomnia. However, many others wake up too early in the morning (“late insomnia”), at least 30 minutes earlier than they want and after less than six and a half hours of sleep. The type of insomnia that a person experiences can change between these during the course of the disorder. These people also may have to deal with low quality sleep that leaves them still feeling tired even if they slept long enough. This is called “non-restorative sleep” and appears in many different sleep disorders.
Steps for diagnosis
The very first part of evaluating insomnia is taking a thorough history. How long the problem has gone on, how frequently does it happen, and how severely does it affect alertness and functioning during the day? This includes assessing routines surrounding sleep and identifying anything that could be disturbing sleep, such as medications, other drugs or substances, and things in the environment that could hinder good sleep. Doctors may ask people to start a nightly diary about their sleep, monitoring multiple aspects of their sleep at night in addition to any treatments they are trying and other habits that may be helping or hurting. Doctors also assess daytime sleepiness using the Epworth Sleepiness Scale, which has people rate how likely they are to doze off in various different daily situations.
Physical exam and blood tests look for any medical conditions that could be contributing as well. A sleep study, also known as Polysomnography, is the final and most definitive tool for determining whether someone has a sleep disorder. These are performed overnight in a hospital or at a sleep evaluation center. The test monitors basic vital signs, such as blood pressure, heart rate, and blood oxygen levels, in addition to brain waves, eye movements, and other body motions throughout a full night’s rest.
Treating Insomnia Disorder
The most effective method is Cognitive Behavioral Therapy, which encompasses a wide spectrum of mental and behavioral techniques to help with poor sleep. The cognitive aspect helps people address the anxiety they have around their insomnia. These people work with a therapist to identify each of their specific points of anxiety and replace those worries with more effective thought patterns. This includes addressing the excessive energy that people spend on how much sleep they should be getting and what will happen if they do not get enough. People can combine this with relaxation techniques, such as progressive muscle relaxation and thought replacement, to help quell the physical and mental aspects of anxiety.
One of the behavioral techniques is called Stimulus Control Therapy. This focuses on making sure a person’s bed and its surroundings are intended only for two activities: sleep and sex. This is related to sleep hygiene and involves keeping the bedroom dark, quiet, and devoid of other distractions. A big part of this is only going to bed when sleepy. If people lie in bed for longer than 20 minutes without going to sleep, they should get out of bed and return only when they are ready to fall asleep quickly. This behavioral training can help to ‘teach’ the brain and body to sleep quickly when going to bed.
Sleep Restriction is a somewhat counterintuitive strategy that involves slightly restricting the amount of time spent in bed. For example, if someone with insomnia feels they only sleep 6 out of 8 hours in bed, they would restrict the time in bed to 6 hours only. This creates a mild sleep deficit, which increases the sleep efficiency (the percentage of time in bed that is spent actually sleeping). They then slowly increase the amount of time in bed over several weeks until they are back to 8 hours of bedtime with almost all of it spent asleep.
Benzodiazepines are very effective at inducing and maintaining sleep. The F.D.A. has approved these for use with insomnia: Halcion (triazolam), ProSom (estazolam), Restoril (temazepam), Doral (quazepam), and flurazepam. Unfortunately, people rapidly develop tolerance, and these medications are also prone to abuse, as in Sedative, Hypnotic, and Anxiolytic Use Disorder. Because of this, long term use beyond a few weeks is not an option. Additionally, benzodiazepines can cause memory problems, slowed thinking, and birth defects as well as increased risk of falls and delirium in the elderly.
Ambien (zolpidem), Sonata (zaleplon), and Lunesta (eszopiclone) offer a safer alternative to benzodiazepines without sacrificing effectiveness. These medications function similarly to benzodiazepines but have a much less severe host of side effects.
Rozerem (ramelteon) offers an effective, non-addictive insomnia treatment with very mild side effects. It works like melatonin and is only useful for helping people get to sleep (rather than stay asleep). Belsomra (suvorexant) is the first in a new line of medications that treat insomnia by working on the sleep hormone, orexin, and helps with both inducing and maintaining sleep.
Certain antidepressants like Silenor (doxepin), Remeron (mirtazepine), and trazodone can help with insomnia, although only Silenor is F.D.A.-approved for it. Over the counter options include medications like Unisom and Benadryl, which contain the anti-histamine diphenhydramine. The hormone melatonin is also sold over the counter, usually as a dietary supplement, and helps with insomnia and sleep-wake cycle disruptions from jet lag and overnight shift work.
Managing Insomnia Disorder
Bad sleep habits
In addition to the medical therapies for insomnia, sleep hygiene is one of the key pieces of the puzzle. These problems are usually identified by a sleep diary, and the interventions are free. Avoid tobacco and caffeine for at least 8 hours ideally before you intend on going to bed. Both increase heart rate, blood pressure, and wakefulness. People have traditionally used alcohol (a “nightcap”) to try to help them sleep. However, the resulting quality of sleep is poor, and people are more likely to wake up in the middle of the night.
Creating a healthy bedroom
Prepare your body and mind for sleep in the time leading up to bed with calming activities like a bathing or reading (not on a screen, but a real book or magazine). Avoid exercise and bright lights, including screens. Follow a regular sleep schedule; try to go to bed and get up at roughly the same times from day to day. If you work a night shift job, make sure your bedroom is dark and quiet while you try to sleep during the day.
Screens and blue light
The reason to avoid screens before bedtime is not just because they emit light but due to the specific kind of light. Melatonin is a hormone released by the brain at night to promote sleep, and all kinds of light prevent the release of melatonin, delaying the onset of sleep. However, electronic screens release higher levels of blue light than the sun, and blue light most powerfully suppresses melatonin levels. Screen time before bed increases the time to fall asleep and reduces the quality of sleep.
Since simply putting down the phone or computer is not an option in our ever-connected modern age, technology does offer some partial solutions. Turning down the brightness of screens at night is the first and easiest step. Many devices also have a “dark theme”, where text appears white on a black background, further reducing the amount of light put out. Apps and the newest devices enable users to reduce specifically the blue light from the screen.