Insomnia: Symptoms, Causes, and Treatments
What is Insomnia?
Insomnia is based on an individual's subjective assessment of how difficult it is to fall asleep and stay asleep. It includes their own assessment of how often they wake up at night and have problems going back to sleep.
Patients will report that their sleep is not restorative, which can lead to them not functioning well and causes distress.
An insomnia diagnosis is not dependent on an external quantification of sleep or a measurement of sleep quality.
Insomnia is a sleep disorder.
It is not the same as Chronic Sleep Deprivation
Insomnia is recognised as a medical condition. It can give rise to various health and performance challenges.
​
Conversely, sleep deprivation is self-imposed. For instance, some people display their "getting away with little sleep" with pride consciously choosing to sleep less. They do not have an inability to fall asleep or stay asleep.
​
Whereas, individuals experiencing insomnia perceive an inability to initiate or maintain sleep.
Sleep studies show that these patients tend to underestimate how much they sleep. They frequently sleep for 4 or 5 hours or more, despite their subjective perception of not getting far less sleep and difficulty falling asleep.
​
Therefore, the potential health risks associated with chronic sleep deprivation may not necessarily be applicable to those experiencing insomnia.
​
An absence of sleep is the defining characteristic of chronic sleep deprivation. Difficulty sleeping is not chronic sleep deprivation.
​
Many clinical studies have looked at the impact on physical and mental health due to short-term total sleep deprivation, or long-standing short sleep durations of less than 4 or 5 hours. These studies found strong associations between short sleep and health problems.
Is there more than one type of Insomnia?
Yes! There are two high-level categories: Primary and Secondary insomnia. Chronic insomnia and Short-term insomnia (also known as acute insomnia) are subcategories of both.
Chronic insomnia
This occurs when difficulty sleeping occurs at least three nights a week for more than three months.
Short-term insomnia
This is defined as difficulty with sleep affecting fewer evenings per week but which resolves within three months.
Primary Insomnia
In this case, the condition is characterised by the disorder itself - an inability to sleep well. It is not caused by a crisis or an underlying health condition such as a low thyroid, or poor sleep hygiene. They are often genetic or learned, or due to unexplained causes. They need medical evaluation and treatment. The good news is that they are treatable!
There are three primary insomnia types. I briefly describe them below.
​
Psychophysiological Insomnia: Primary and Chronic
This is the most common and most of my patients are in this group.
This is a learned behaviour that begins with worrying about sleep which then causes anxiety, which then prevents sleep. Sleeplessness becomes a self-fulfilling prophecy and a positive feedback loop begins.
The more someone thinks about sleep and focuses on "trying" to sleep, the harder it becomes. Just like acquiring a new skill, this behaviour hardwires sleeplessness over time.
Adjustment insomnia, which I discuss below, can sometimes lead to Psychophysiological insomnia if it does not resolve spontaneously.
Controlling insomnia symptoms early in the acute period is crucial.
The best approach for treatment:
Ask any good sleeper if she has trouble falling asleep, you will likely receive a blank expression. She just sleeps and doesn't think about it. It just happens.
​
If we could purposefully forget things, and forget about worrying about sleep, we could quickly fix this widespread sleep disorder. However, we cannot purposefully forget, therefore we must relearn how to fall asleep normally.
​
The main method of treatment here is Cognitive Behavioural Therapy for Insomnia (CBTi). Numerous clinical trials have shown its superiority over any prescription medication, or natural remedy, especially in long-term outcomes.
​
The American Academy of Sleep Medicine lists CBTi as the only treatment "recommended" for chronic insomnia. However, CBTi can be demanding.
​
Often a patient requires medication for some time to control severe insomnia in the short-term to then be able to undergo a CBTi programme. CBTi can be accessed through trained therapists, online courses and self-help books.
​
In my experience, it works better with personal guidance by a therapist in combination with a sleep physician who can prescribe and titrate medication as needed and as the patient progresses.
Paradoxical Insomnia: Primary and Chronic
Many persons who suffer from chronic insomnia believe they receive no or very little sleep for long periods of time. Despite feeling fatigued and desperate for sleep, they do not fall asleep in quiet places, nor do they take, or are able to take naps.
​
When these people get sleep studies, they are astonished to learn that their overall sleep time is many hours longer than they believe. This is sometimes the normal sleep duration of 7-8 hours.
​
Patients with this diagnosis mistrust that the sleep study was accurate and feel that the sleep expert is trying to trick them. This complicates the patient-doctor relationship, and many patients see multiple doctors without relief.
​
It is crucial to remember that insomnia is based on the subjective experience of the lack of sleep, not on any objective measure of sleep duration.
​
The best approach for treatment:
Creating a trusting doctor-patient relationship and enabling the patient understand their situation without feeling "caught out" or offended is the hardest task.
​
A thorough explanation of facts surrounding sleep physiology helps at the start of treatment. Sleep tests help quantify total sleep and detect other sleep disorders. Reframing sleep beliefs and attitudes with CBTi can be helpful.
​
Sleep medications can assist, but they typically fail because patients don't notice their effect. Extending sleep with drugs may not help because a patient may not perceive the additional sleep duration, neither. A multi-modal therapy programme is better.
​
Idiopathic Insomnia: Primary and Chronic
Childhood onset is the hallmark of this condition and it is quite rare (<1%). Some people have sleep difficulties start in childhood and persist throughout their lives. Often, other family members are also affected which suggests a genetic component. Other causes cannot explain this situation.
​
Other forms of insomnia can develop as co-morbidities. Poor sleep patterns, inadequate routines, poor sleep environment or anxiety about getting a good night's sleep can, e.g. cause psychophysiological insomnia.
​
The best approach for treatment:
Depending on severity, some individuals need lifelong prescription medication and good sleep habits.
Secondary Insomnia
The diagnosis here is associated with and caused by other medical conditions like hyperthyroidism, Cushing's Syndrome (too much cortisol), metabolic problems, and mental health difficulties like depression and anxiety. This condition is often complex and may include primary insomnia as well.
​
Prescription drugs and recreational substances can cause sleeping difficulties.
Sleep disorders like sleep apnea, restless legs syndrome, periodic limb movements, REM sleep behaviour disorder, and nightmares can make falling asleep difficult and disrupt sleep.
A noisy sleep environment or an uncomfortable mattress can also lead to trouble sleeping.
​
The best approach for treatment:
Careful medical history and physical examination are part of insomnia patient assessment. Excluding physical or mental diseases may require additional diagnostic tests.
Treatment should focus on underlying problems. Medication changes may be needed to avoid sleep-impairing side effects.
​
Short-term sleep-inducing medicine may help if sleep problems persist. Patients with depression and/or anxiety should take a sleep-inducing antidepressant.
​
People typically underestimate nightmares as a cause of insomnia, and many drugs can worsen them, such as beta-blockers.
​
Complex situations where sleep quality and other health conditions interact require a multi-disciplinary approach.
​
Adjustment Insomnia: Secondary and Short-Term
Crisis situations that disturb sleep usually prompt this. Extreme stress and crises do disrupt sleep. Response to crises vary and there seems to be a genetic component to how much stress can overwhelm a person. Some develop stomach ulcers, others headaches, skin rashes,
palpitations, shortness of breath, abdominal cramps, diarrhoea, etc..
​
Adjustment insomnia is self-limiting and short-term. However, if the stressors and circumstances of the crisis endure or if the problem continues after the crisis it becomes either a Secondary Insomnia due to a mental health condition (e.g., Post-Traumatic Stress Disorder, or depression), or into a Primary Psychophysiological Insomnia.
​
The best approach for treatment:
Treatments should alleviate acute symptoms and prevent sleep problems from becoming chronic. Short-term usage of benzodiazepines (sedatives) or Z-drugs (Zopiclone and Zolpidem in the UK) can help.
​
Avoiding dependency on drugs and preventing short-term insomnia from turning into chronic must be the goal. A long-term treatment strategy, right from the beginning is essential.
​
This strategy needs to be tailored and consider the patient's physical health, mental health, and external circumstances; review their sleep habits, sleep cycle, sleep patterns, and chronotype, and build a calming nighttime routine.
​
Inadequate Sleep Hygiene: Secondary and Short-, or Long-Term
After excluding Secondary Insomnia, contributing factors include the patient not having or getting adequate time in bed, a stable sleep schedule, and a sleep-friendly atmosphere.
They should not go to bed at a time that's against their chronotype, bring work to bed (laptop, phone, etc.), spend too much time in bed, and have inconsistent bedtimes.
​
The best approach for treatment:
Sleep medications should be avoided in this situation. A comprehensive sleep history (often with sleep tracker data) frequently exposes problematic factors, and advice should focus on sleep education and practical ways to improve risk factors.
How is insomnia diagnosed?
The sleep-wake pattern is the first step in diagnosis. Sleep diaries are helpful but not always enough.
​
Actigraphy, a wrist-worn medical-grade sleep tracker, can measure sleep length and timing.
​
Identifying insufficient sleep, poor sleep habits, and paradoxical insomnia is crucial. Objectively obtained data is important in helping with a differential diagnosis. Differentiation is key to choosing the optimal treatment. A person's chronotype should also be considered.
​
Identifying medical and mental disorders that cause sleeplessness is important. A thorough drug history (prescription and recreational) may potentially indicate sleep disturbances. Common drugs like beta-blockers and some antidepressants can induce sleep problems.
​
Alcohol and marijuana may calm a person before bed, but they disturb healthy sleep architecture causing more disruptions to sleep and can destroy a person's body clock possibly permanently.
Obstructive sleep apnoea, restless legs, periodic limb movement disorder, and parasomnias may require more sleep investigations.
​
Polysomnography, the most comprehensive sleep study, records biosignals such as heart rate, breathing effort, airflow, blood oxygen saturation, muscle tone, limb movements, eye movements, and brain waves using many electrodes and sensors.
​
Sleep labs at a sleep centre perform polysomnography overnight. Some providers offer home polysomnography, letting patients sleep at home. Most insomnia instances do not require polysomnography.
​
Nightmares, especially for those with or without PTSD, can worsen sleeplessness. Sleep tests, including polysomnography, don't reveal much about dreams, although some sleep disorders might worsen them, such as obstructive sleep apnea, which can cause nightmares and insomnia.
Can you treat Insomnia?
​
Yes!
Sleep Routine
The first step in any insomnia treatment is to make sure that sleep is given a fair chance. The Sleep Foundation outlines the elements of good sleep habits: https://www.sleepfoundation.org/sleep-hygiene
​
The sleep-wake pattern is the first step in diagnosis. Sleep diaries are helpful but not always enough.
​
Actigraphy, a wrist-worn medical-grade sleep tracker, can measure sleep length and timing. Identifying insufficient sleep, poor sleep habits, and paradoxical insomnia is crucial.
Objectively obtained data is important in helping with a differential diagnosis. Differentiation is key to choosing the optimal treatment. A person's chronotype should also be considered.
Identifying medical and mental disorders that cause sleeplessness is important. A thorough drug history (prescription and recreational) may potentially indicate sleep disturbances.
Common drugs like beta-blockers and some antidepressants can induce sleep problems.
Alcohol and marijuana may calm a person before bed, but they disturb healthy sleep architecture causing more disruptions to sleep and can destroy a person's body clock possibly permanently.
​
Obstructive sleep apnoea, restless legs, periodic limb movement disorder, and parasomnias may require more sleep investigations.
​
Polysomnography, the most comprehensive sleep study, records biosignals such as heart rate, breathing effort, airflow, blood oxygen saturation, muscle tone, limb movements, eye movements, and brain waves using many electrodes and sensors.
​
Sleep labs at a sleep centre perform polysomnography overnight. Some providers offer home polysomnography, letting patients sleep at home. Most insomnia instances do not require polysomnography.
​
Nightmares, especially for those with or without PTSD, can worsen sleeplessness. Sleep tests, including polysomnography, don't reveal much about dreams, although some sleep disorders might worsen them, such as obstructive sleep apnea, which can cause nightmares and insomnia.
However, adhering to those habits are often not enough to treat insomnia and further measures are needed to repair the sleep-wake cycle.
Prescription Medication for Sleep Disorders
Preventing insomnia requires addressing contributory factors like medical or psychiatric problems, medications, recreational drugs, and bad sleep habits. While treating these, insomnia may require short-term treatment.
​
When insomnia is acute and time-limited, many patients benefit from treatment with antihistamines, benzodiazepines, or Z-drugs (zopiclone or zolpidem) in the short term.
They are ineffective and hazardous for chronic insomnia. Long-term tolerance and dependency on certain drugs can cause cognitive deterioration.
​
Sedatives, especially in the elderly, can increase nighttime falls. Chronic insomnia treatment often begins with slowly withdrawing such medications.
​
Sedative antidepressants (e.g., mirtazapine, trazodone, paroxetine), anti-epilepsy medicines (e.g., pregabalin), anti-psychotics (e.g., quetiapine), and others can help with insomnia. Other medical conditions of the patient often influence the drug choice. Consulting a sleep doctor is recommended to assist here.
​
Over the Counter Medicines and Herbal Remedies to help you fall asleep
For most people, the first stop is the local pharmacy or health store. Typical OTC sleep aids contain sedating antihistamines. For short term, or the occasional night, these can be helpful. For longer-term, or daily use they are not recommended.
​
There are also a number of herbal preparations that aid sleep: valerian root, lemon balm, ashwagandha, black cohosh, chamomile, and several others. None of them are recommended by the American Academy of Sleep Medicine, or by the National Institute of Clinical Excellence. Nevertheless, they can be helpful and are worth a try.
​
For people with restlessness, magnesium supplements can be helpful.
​
CBD preparations are increasingly popular for several medical and mental health conditions, including insomnia. Some find CBD formulations energising, while others swear by its drowsiness effects.
​
The quality of CBD preparations on the market varies greatly, with some containing scarcely any CBD and higher quality ones being pricey.
​
For sure, THC, the psychoactive ingredient in marijuana, while relaxing, is bad for sleep quality and the effect of smoking a single joint can last for several days. I advise strongly against THC as a sleep aid.
​
Similar concerns apply to alcohol as a sleep aid. Alcohol alters sleep architecture and induces nighttime arousal after sedating. Severe alcohol misuse might permanently damage our body clock and 24-hour sleep-wake cycle. I strongly advise against using alcohol as a sleep aid.
​
​
Cognitive Behavioural Therapy for Insomnia (CBT-i)
CBTi is the mainstay of treatment for chronic insomnia. The Sleep Foundation provides a helpful overview: https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia.
​
Several clinical trials and real-world testing have shown that CBTi works. However, it requires great commitment by the patient and takes time to work. Online self-help programmes, books, and highly trained therapists offer it and I encourage its use.
​
Many patients will need prescription medications to overcome their acute insomnia crisis so they can constructively engage with CBTi. Medication may be needed alongside a CBTi programme to bridge the time until CBTi takes effect, or even long-term, especially if an anxiety disorder significantly contributes to the patient's insomnia.
Melatonin
Misuse and misinterpretation of melatonin are common. Every night, our pineal gland produces this neuro-hormone also called the "hormone of darkness". Humans are diurnal animals and melatonin functions to prepare the human brain for sleep. Melatonin levels also rise at night in nocturnal animals, but in them act to boost alertness.
​
It is not a sleeping pill and its effectiveness as such is not proven. Melatonin works best when taken to affect a person's body clock and move the natural sleep-wake cycle to a more sleep-friendly time, such as for jet lag, or to help a night owl get to sleep sooner so they can get ready in the morning.
​
It can also assist older people in maintaining sleep. It's best used by a sleep doctor.
​
​
Other Methods
Daylight, especially in the morning, is crucial for a healthy 24 sleep-wake pattern. Avoiding melatonin suppression in the evening necessitates restricting strong light.
​
Several relaxing techniques treat insomnia. A simple strategy like progressive muscle relaxation or autogenic training is excellent for nighttime use, although personal choice is key.
​
Recent advances in data processing and electrode technology have brought neuro-feedback out of the lab into daily life. Early studies suggest their efficacy, but the procedure is still new and has yet to become a mainstream insomnia therapy.
​
Overlooked but powerful, exercise improves sleep and overall health. Practical and sustainable exercise should be part of every insomnia treatment regimen. Yoga is becoming more popular for insomnia.
If you would like to read more about insomnia:
-
American Academy of Sleep Medicine: https://aasm.org/resources/factsheets/insomnia.pdf
-
Sleep Foundation: https://www.sleepfoundation.org/insomnia