Ever had the disheartening realization that the birds are chirping and the first signs of dawn are approaching after tossing and turning for hours on end? We’re all familiar with an occasional restless night, but what if this trend repeats for days, weeks, or months on end? 

If you think you may suffer from insomnia, know that you are not alone, this is one of the most common sleep disorders out there.

Insomnia is a sleep disorder that is associated with repeated difficulty falling asleep, staying asleep, and waking up too early. This results in poor quality sleep that can generate severe daytime drowsiness and other problems such as poor concentration and focus.[1

The exact criteria are variable, as there are multiple types of insomnia. But generally the symptoms of insomnia include taking longer than 30 minutes to fall asleep, or awakening for extended periods throughout the course of the night and as a result sleeping fewer than six hours per night.

Insomnia is the result of interactions among various biological, psychological, physical, medical, and environmental factors.

Effects of insomnia 

Compared to people getting normal amounts of sleep, people with insomnia are more likely to experience the following:[2]

  • Greater chance of depression and anxiety.
  • Higher scores on arousal scales, meaning that they awake more easily.
  • Longer periods to fall asleep during the daytime, called daytime sleep latency.
  • Increased 24-hour metabolic rates. 
  • Greater variability in their sleep from one night to another.
  • More electroencephalographic (EEG) activity, which is the brainwave pattern measured during memory processing and performing tasks at sleep onset.
  • Increased overall glucose use during the transition from waking to sleep onset as measured by positron emission tomography (PET) of the brain.

The optimal duration of sleep is seven to nine hours per night. Shorter duration of sleep is associated with adverse outcomes. For example, a lack of sleep is a commonly cited cause of car accidents. It is also associated with occupational and home-based mishaps and accidents while operating machinery. 

The annual cost of insomnia is estimated at $12 billion for medical care and $2 billion for sleep-promoting agents like supplements or pharmacologic agents. 

Types of insomnia

There are multiple different types of insomnia depending on when they occur in the sleep cycle, what causes them, and what effects they may have on a person. The causes of insomnia can be from wide-ranging medical, psychiatric, environmental, or situational problems.

Initial insomnia 

Initial insomnia is defined as the inability to fall asleep at the beginning of the sleep cycle. This type of insomnia frequently leads to anxiety over not being able to fall asleep and a vicious cycle of sleeplessness. 

Having to awaken at a specific time for a special event like a test or a job interview can make the matter even worse.

Middle insomnia

Middle insomnia is the difficulty in staying asleep once asleep and is called sleep-maintenance insomnia.  Waking up for short periods between sleep cycles in natural and healthy but when the period of wakefulness lasts for an extended period and the mind starts to become more alert, these are the sorts of disruptions associated with Middle insomnia.

These disruptions can also associated with medical conditions such as bladder instability, pain syndromes, medical illnesses, and depression.

Terminal insomnia

Terminal insomnia or late insomnia is early morning awakening before the intended time or before adequate rest has occurred. Depression and anxiety are common reasons for this form of insomnia.

Parasomnias

Etymologically, Parasomnia means “around sleep time”. This refers to unusual actions or experiences associated with being asleep such as nightmares, sleep terrors, and sleepwalking. 

Dyssomnias

Dyssomnias means abnormal sleep time and affects the duration of sleep, quality, or timing of the onset of sleep. Examples include primary insomnia, sleep apnea or breathing-related sleep disorder, and circadian rhythm sleep disorder.

Orthosomnia

The newest form of insomnia, orthosomnia, is associated with sleeplessness caused by anxiety brought on by sleep trackers reporting poor sleep quality.

For some individuals, monitoring sleep quality and quantity generates enough anxiety and sleep perfectionism to limit their ability to fall asleep. Learn more from our sleep tracker article.

How is Insomnia diagnosed?

Insomnia is a clinical diagnosis as well as a subjective one, which means that no one specific test can make the diagnosis and the person’s perception of their sleep satisfaction factors in as well. 

Measurements of subjective sleep quality include the initiation of sleep, ability to maintain sleep, depth of sleep, dreams, getting up after sleep, condition after sleep, the effect of sleep on daily life, amount of sleep and satisfaction with sleep.[7]

The Sleep Quality Score (SQS) is another test that measures subjective factors consisting of 28 items and six domains of sleep quality defined as:[6]

  • Daytime symptoms. 
  • Restoration after sleep.
  • Problems initiating sleep.
  • Problems maintaining sleep. 
  • Difficulty waking. 
  • Sleep satisfaction. 

The medical definition of insomnia is dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: [8]

  • Difficulty falling asleep.
  • Difficulty maintaining sleep, frequent awakenings or problems returning to sleep after awakenings.
  • Early-morning awakening with inability to return to sleep.
  • Chronic insomnia is when you experience these symptoms for a period of over a month.

Other criteria include the frequency and duration of the sleep problem, whether it causes distress or impairment in core spheres of life such as one’s social life or work, whether there is adequate time provided for sleep, and whether another sleep problem coexists with insomnia.  The potential presence of coexisting mental or medical conditions, such as an anxiety disorder or chronic pain, also contributes towards an insomnia diagnosis.

How do doctors evaluate insomnia?

The American Academy of Sleep Medicine (AASM) guideline for diagnosing people with insomnia suggests that a medical questionnaire be completed, which consists of a series of questions about an individual’s medical and surgical history, family history of sleep problems, medications used, when the condition started, what effects insomnia has on their life. Social and lifestyle questions such as caffeine, smoking, drug, and alcohol intake are also important factors that are captured.  

In addition, a sleep history is compiled, capturing factors including sleep timing, sleep habits, symptoms related to daytime sleepiness or those that may contribute to insomnia. This would be followed by a psychiatric evaluation to assess any potential mood disorders such as depression and anxiety. This is accomplished with self-tests, such as the Beck Depression Inventory test.[3] 

A sleepiness assessment, such as the Epworth Sleepiness Scale, can also be completed, which rates a person’s chances of dozing off under certain circumstances or activities[4]

A two-week sleep log is a good way to get a clearer picture of a person’s sleep-wake cycles.[5] Keeping a sleep log is a good way to get a sense of how well you are sleeping and if there are particular patterns that present themselves.

Other sleep tests

Here are some other tests that may be used to diagnose sleep-related disorders. 

  • Studies for oxygen content which may point to sleep apnea as the underlying cause. Since there are therapies for sleep apnea, identifying the type and severity of sleep disturbance will help guide therapy.
  • Polysomnography, which is a common clinical sleep study administered at a sleep center, records your brain waves to track how your body moves through the phases of sleep, the oxygen level in your blood, your heart rate, breathing, and eye and leg movements.
  • Polysomnography and daytime multiple sleep latency testing (MSLT) are not done routinely for insomnia except if sleep apnea is suspected and in patients who have sudden arousals or injurious behavior. Restless legs syndrome and treatment failures are other reasons to do polysomnography.[10,11]
  • Daytime multiple sleep latency testing (MSLT) or the Daytime Nap study to measure how fast you fall asleep during the day in a quiet environment.
  • Actigraphy is the continuous measurement of daytime movement using a small device. It can help document sleep patterns and circadian rhythms. 
  • Genetic testing for rare sleep disorders such as fatal familial insomnia (FFI), especially if there is a suspected family history.
  • Brain imaging for FFI. Via positron emission tomography. 

Cognitive Behavioral Therapy and insomnia

Cognitive Behavioral Therapy (CBT) is the most effective long-term treatment for patients with insomnia. It teaches you to identify your thoughts and change beliefs surrounding your insomnia. CBT can control or reduce negative thoughts and worries that keep you awake or make falling asleep difficult. CBT consists of the following:[9] 

  • Education about sleep habits or hygiene. 
  • Cognitive therapy.
  • Relaxation therapy.
  • Stimulus-control therapy.
  • Sleep-restriction therapy- scheduled sleep-wake times.

CBT improves sleep in 75-80% of insomnia patients. There is less use of sleeping pills in up to 90% of patients who undergo CBT. Even patients with other medical conditions can benefit from CBT while being treated for their problem. A short course of a sedative-hypnotic or melatonin promoting agent along with an antidepressant medication may be sufficient.

The problem with CBT is that it is time-consuming and must be administered by a trained professional such as a psychologist. Usually, there are five to six sessions over six to seven weeks with each session lasting 20-40 minutes.  The optimal frequency is four biweekly individual treatments.[12]

Another form of therapy is called brief behavioral treatment for insomnia (BBTI) that is given in two sessions and two telephone interactions.[13]

Insomnia medications

There are several medications that have been developed to treat short-term insomnia, all of which have only been clinically tested for short periods of use of less than two weeks. 
To date, there are no insomnia medications intended for treatment of chronic insomnia, which is defined for insomnia lasting over one month.

Here are some of the main classes of prescription sleep medications and a little bit about how they work. 

This table outlines which types of insomnia these sleep medications are typically prescribed for:

Sleep-Onset Insomnia

Sleep-Maintenance Insomnia

Both Sleep-Onset AND Sleep-Maintenance Insomnia

Eszopiclone

Zaleplon

Zolpidem

Temazepam

Triazolam

Ramelteon

Eszopiclone

Zolpidem

Temazepam

Doxepin

Suvorexant

Eszopiclone

Zolpidem

Temazepam


These medications have been shown to improve sleep to varying degrees. This article outlines what each of these drugs has been clinically demonstrated to achieve, their side effects, and their potential interactions.

How to treat insomnia

The behavioral changes you make to improve your sleep are often the most effective way to overcome insomnia. Remember that one-third of your life you spend sleeping impacts the other two-thirds of your waking life, so learning good habits and sleep hygiene are the first steps to the healthy life you want.

In 2015, the American Thoracic Society (ATS) released a statement outlining the importance of achieving good-quality sleep and avoiding sleep deprivation. Their recommendations include the following:[14]

  • Good-quality sleep is essential for good health and quality of life.
  • Short sleep duration (6 hours or less per 24-hour period) is associated with worse outcomes.
  • Long sleep duration (>9 to 10 hours per 24-hour period) may also be associated with poor health outcomes.
  • The optimal sleep duration in adults for good health is 7 to 9 hours, but individuals may find this varies throughout their lifetime.
  • Drowsy driving is an important cause of fatal and nonfatal motor vehicle crashes. Education should be given on how to recognize the symptoms and consequences of drowsiness.
  • Better education about shift work and workplace injuries from sleep-related problems.
  • Many individuals with sleep disorders are undiagnosed and not treated.
  • Age-based recommendations for sleep duration in children are different than adults, and school schedules may need to be adjusted.

Medications that can contribute to insomnia:

Some medications can make it more difficult to sleep. Here is a list of medications that are known to interfere with sleep:

  • Beta blockers-often used for high blood pressure.
  • Clonidine
  • Theophylline
  • Certain antidepressants 
  • Over-the-counter or prescribed decongestants
  • Stimulants

Do you have insomnia?

If the answer is yes, know that you’re not alone and that insomnia can be overcome by finding the right actions. Speak to your doctor or healthcare provider for advice. Learning about sleep hygiene and the importance of a consistent sleep schedule is a great start to achieve better sleep.

Sleep coaching can be a helpful way of addressing your sleep problems prior to trying drug interventions. 

At Remrise, we look at tackling sleep troubles through integrated solutions. Check out the app for more.

References

  1. https://www.ncbi.nlm.nih.gov/pubmed/15683149
  2. Thorpy M. J. (2012). Classification of sleep disorders. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 9(4), 687–701. doi:10.1007/s13311-012-0145-6
  3. https://www.ismanet.org/doctoryourspirit/pdfs/Beck-Depression-Inventory-BDI.pdf
  4. https://www.sleepapnea.org/assets/files/pdf/ESS%20PDF%201990-97.pdf
  5. http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf
  6.  https://doi.org/10.1111/j.1365-2869.2006.00544.x
  7. https://www.med.upenn.edu/cbti/assets/user-content/documents/Sleep%20Quality%20Scale%20(SQS).pdf
  8. American Academy of Sleep Medicine. ICSD2 - International Classification of Sleep Disorders. Diagnostic and Coding Manual. 2nd. Westchester, Ill: American Academy of Sleep Medicine; 2005. 1-32.
  9. https://www.sleepfoundation.org/articles/cognitive-behavioral-therapy-insomnia
  10. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008 Oct 15. 4(5):487-504. [Medline][Full Text].
  11. Chesson A Jr, Hartse K, Anderson WM, Davila D, Johnson S, Littner M, et al. Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2000 Mar 15. 23(2):237-41. [Medline].
  12. Edinger JD, Wohlgemuth WK, Radtke RA, Coffman CJ, Carney CE. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep. 2007 Feb 1. 30(2):203-12. [Medline].
  13. Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011 May 23. 171(10):887-95. [Medline]
  14. Mukherjee S, Patel SR, Kales SN, Ayas NT, Strohl KP, Gozal D, et al. An Official American Thoracic Society Statement: The Importance of Healthy Sleep. Recommendations and Future Priorities. Am J Respir Crit Care Med. 2015 Jun 15. 191 (12):1450-8. [Medline].