Insomnia. At one time or another, most of us have experienced its bothersome symptoms: difficulty falling asleep, staying asleep, or both. We may have suffered bouts of insomnia that last a few days, or much longer. Though the symptoms may seem simple enough, insomnia is a complex condition with a wide variety of causes.
Insomnia is also an extremely common problem — too common, in fact. Thirty to forty percent of Americans report having experienced symptoms of insomnia in the past year, while ten to fifteen percent suffer from insomnia chronically. (1)
Insomnia is classified as a sleep disorder, and is defined as the inability to fall asleep and/or stay asleep, or not feeling rested after sleep. It may be transient, acute, or chronic. Insomnia is by far the most common sleep disorder, affecting as much as half the world’s population at some point in their lives.
One of the defining features of insomnia is that it interferes with daytime functioning. (2) This difficulty may take the form of fatigue, trouble concentrating, irritability, or memory lapses. Microsleep episodes may occur, along with impulsiveness or depression.
Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t taken as medical advice, and it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately.
The symptoms of insomnia are the inability to fall asleep, stay asleep, or fall back to sleep. Though many insomniacs experience a range of additional physical and cognitive consequences, these are not primary symptoms, and may be shared by those suffering from sleep deprivation and other sleep disorders. Insomnia can, however, produce a wide range of effects, including:
- Feeling tired and/or groggy upon waking up
- Daytime fatigue
- Anxiety or depression
- Irritability or mood swings
- Difficulty concentrating
- Trouble retaining new information
- Reduced coordination
- Increased errors and accidents at home or on the job
- Diminished work performance
- Trouble engaging in social activities
In addition, insomnia sufferers may experience impaired decision-making (3), relationship difficulties, and reduced quality of life. To fall or stay asleep, they may over-rely on sleeping pills or supplements. Sleep-related anxiety that begins with a transient bout of insomnia may become a persistent issue.
Insomnia symptoms can range from mild to severe, and fluctuate over time. It is possible for symptoms to improve during different times of life and then recur.
Insomnia Fact: A person who sleeps less than the average seven to nine hours each night but does not suffer from symptoms of insomnia may be what’s called a “short sleeper.” Short sleepers feel refreshed on less sleep than is usual for most of us, often five hours or fewer
Insomnia Vs. Sleep Deprivation — What’s the Difference?
Because insomnia and sleep deprivation share some physical and cognitive effects, they may be confused. Though both can result in a feeling of fatigue or trouble concentrating, they are not the same. Sleep deprivation is willingly depriving oneself of sleep. Insomnia is the inability to sleep, stay asleep, or get back to sleep.
A person may experience sleep deprivation while studying for exams, traveling, or attending to a sick child. If offered the opportunity, the person who is sleep-deprived is able to sleep. The person suffering from insomnia, however, can’t sleep even when given the chance. Insomnia concerns sleep quality, while sleep deprivation concerns sleep quantity.
Insomnia and sleep deprivation may have some important differences, but aren’t the symptoms the same? Not exactly. Sleep deprivation can result in daytime sleepiness, poor concentration, memory problems, and decreased emotional control. Some studies show similar deficits in people suffering from insomnia, but there are some significant distinctions.
Hyperarousal of the sympathetic nervous system may be at play in some cases of chronic insomnia, preventing sleep and a feeling of sleepiness at night. (4) This hyperarousal may also prevent insomnia sufferers from experiencing the same daytime sleepiness and cognitive impairments experienced by those who are sleep-deprived, even when they operate on the same amount of sleep.
This could mean that current testing techniques don’t adequately show the physical and cognitive effects of chronic insomnia, or it could mean that, though insomniacs are similarly affected by lack of sleep, hyperarousal of their nervous systems overrides these impairments, allowing them to feel more alert.
Another difference between those who are sleep-deprived and those suffering from insomnia is the ability of sleep-deprived people to fall asleep quickly when given the chance to sleep. Even when deprived of their usual amount of sleep, chronic insomniacs tend to fall asleep less quickly than the sleep-deprived, wake up sooner, and have more trouble staying asleep.
Insomnia Symptoms and their Causes
Insomnia used to be divided into two categories — primary and secondary. Primary was thought to be insomnia without an apparent cause, while secondary was thought to be caused by something else, such as another medical condition, mood disorder, or medication. These categories are no longer as commonly used, however, and recent research shows that nearly all cases of insomnia have a discernible cause.
Insomnia symptoms are common, while insomnia disorder is less so. Insomnia symptoms are experienced by many of us periodically throughout life, and may be the result of:
- Mood disorders such as depression
- Grief or trauma
- Chronic pain
- Sleep disorders, like restless leg syndrome and sleep apnea
- Medications, especially those with a stimulant effect, such as ADHD treatments and decongestants
- Jet lag or daylight saving time
While the symptoms of insomnia may come and go, they often resolve by themselves when a stressor passes, an illness is treated, or a usual sleep routine resumes. Treatment is typically unnecessary, though the anxiety and negative associations of the symptoms may persist, contributing to a feeling of wakefulness at night and the possible development of insomnia disorder.
Insomnia Disorder and Its Causes
Insomnia disorder goes beyond the symptoms of insomnia. Commonly known as chronic insomnia, insomnia disorder occurs at least three nights each week for three months or longer. Approximately 10% of adults in the US have insomnia disorder.
Contradictory as it may seem, insomnia disorder has little to do with the amount of time spent asleep. Insomnia disorder concerns the inability to fall asleep, stay asleep, or fall back to sleep.
Insomnia disorder typically results from a negative conditioned response to bedtime, the attempt to sleep, or the sleeping environment. Less commonly, it may be caused by neurological difficulties such as head injuries.
A negative conditioned response to sleep may cause hyperarousal of the body’s sympathetic nervous system. This can increase heart rate and cortisol secretion, and elevate metabolic rate both during sleep and waking hours. Studies of identical twins support the hypothesis that hyperarousal of the body’s systems may contribute to chronic insomnia. (5)
In addition, there may be fundamental differences in the brains of insomniacs as compared to those who sleep well. These differences could be another aspect of the hyperarousal that may be present in those who suffer from chronic insomnia. (6)
Though symptoms of insomnia may be caused by such varied factors as job stress and drinking alcohol (7), these generally are not the cause of insomnia disorder. Insomnia disorder is chronic, and often resistant to typical treatments for short-term sleep difficulties.
Causes of Insomnia Symptoms in Women
For women, hormonal changes, menopause, and pregnancy may contribute to the inability to sleep. Women are also more likely to report suffering from insomnia symptoms, particularly as they get older. This may be due to hormonal differences, a theory supported by studies which show changes in sleep habits between boys and girls beginning in puberty. (8)
Women suffer in greater numbers than men from medical conditions that may cause symptoms of insomnia, including certain autoimmune diseases, migraines, and pelvic pain. They are more at risk of osteoporosis, which can cause joint and spinal pain and make sleep challenging.
In addition, women are more likely to experience the responsibilities of single parenting and primary caregiving for older relatives. These stressors may contribute to higher rates of insomnia symptoms, as well as fewer hours available to sleep.
How is Insomnia Diagnosed?
A diagnosis of insomnia can usually be made by simple self-reporting of symptoms by a patient. Because people undergoing sleep studies often sleep less than they would in their usual environment, such studies are rarely helpful for diagnosing insomnia disorder. (9)
In addition to information about your symptoms, a doctor may:
- Ask about your sleep habits and social environment
- Suggest you keep a sleep diary to track your sleep patterns and identify factors that might contribute to your insomnia issues
- Ask that you take one or several insomnia tests to better understand your sleep habits. These might include questionnaires such as the Insomnia Severity Index or a mental health examination
Insomnia Fact: Human beings are the only mammals known to willingly delay sleep
Insomnia: Three Sub-types, Three Stages
A diagnosis of insomnia may be further broken down into more detailed sub-types and stages. The three main insomnia sub-types are differentiated by the duration of the condition. Though the symptoms are similar, prognosis and treatment may change according to final diagnosis.
The Three Main Sub-Types of Insomnia
1. Transient Insomnia Symptoms. Sleeplessness that lasts from a few days to a few months, and is either intermittent or continuous. The anxiety that may accompany transient insomnia symptoms can put sufferers at risk of developing chronic insomnia. Causes of these symptoms may include:
- An emotionally stressful event, such as a death, new job, move, or birth of a baby
- Poor sleep hygiene. Noise, bright light, late meals, use of electronics, alcohol, and caffeine are common contributors to transient insomnia
- A circadian rhythm disruption, such as jet lag or change in work schedule
- A new sleep environment, such as a hotel room, new bed, or unfamiliar house
- Adjustment to a higher altitude
2. Acute Insomnia Symptoms. (10) Sleeplessness that persists up to three months. Like transient insomnia, acute insomnia may come and go. Common triggers include:
- Emotional conflict or difficulty
- Shift work
- A death or traumatic event
- Pain or illness, such as sleep apnea, asthma, acid-reflux disease, or diabetes
- A stressful life disruption such as a divorce or move
3. Chronic Insomnia, or Insomnia Disorder. (11) Insomnia symptoms that persist for three months or longer. Though there are many causes of insomnia symptoms, there usually are only a few causes of insomnia disorder. Insomnia disorder is typically the result of:
- A conditioned response to bedtime, the attempt to sleep, or the sleeping environment. Hyperarousal of the sympathetic nervous system may be part of this response. The majority of insomnia disorder is the result of this type of conditioning
- Head injuries and other medical conditions. These cause a proportionally small number of insomnia disorder cases
The Three Stages of Insomnia
The experience of insomnia may be different according to the time of night during which it occurs. It may happen at the beginning of the night, during the night, or early in the morning, and may have a different trigger depending on when it takes place. An insomnia sufferer may go through one or all of these stages, which may happen every night, or come and go. The three stages include:
1. Onset Insomnia. The definition of onset insomnia is the inability to fall asleep for more than 30 minutes after going to bed. This type of insomnia is often associated with a conditioned negative response to bed, as well as elevated levels of anxiety and hyperarousal of the nervous system.
2. Middle Insomnia, also known as Sleep Maintenance Insomnia. Middle insomnia is characterized by waking during the night, and extended periods of time spent awake. This sort of insomnia may be the result of illness, another sleep disturbance such as nightmare disorder, or chronic pain. Another common cause of middle insomnia is consumption of alcohol. Though alcohol may make falling asleep easier in some cases, it can lead to waking during the night once the central nervous system effects wear off.
3. Late Insomnia. Waking too early in the morning is the defining feature of late insomnia, which may be experienced during the aging process as sleep patterns change. It is also a common symptom of mood disorders like depression. Stress and anxiety can create a sort of internal “alarm” that leads to consistent early-morning awakening.
Insomnia treatments may be tailored to a sufferer’s particular sub-type and stage of sleep disturbance. For instance, those experiencing grief may have transient insomnia symptoms and wake early in the mornings, while those with chronic pain may lie awake or be unable to fall back to sleep during the night. Psychotherapy may be helpful for some sufferers, while others may benefit from cognitive behavior therapy and restriction of time spent in bed.
How Can Narcolepsy Cause Insomnia Symptoms?
Narcolepsy is perhaps the best-known type of hypersomnia, a range of sleep disturbances characterized by unusual daytime sleepiness and excessive time spent sleeping. Narcolepsy appears to be an autoimmune disease triggered by a viral illness, usually in childhood or adolescence.
Symptoms of narcolepsy include sleeping up to sixteen hours each day or more, needing to take naps after a full night’s sleep, grogginess, suddenly muscle weakness while laughing or experiencing strong emotion, and…insomnia?
It may seem impossible for insomnia symptoms and narcolepsy to co-exist, but often they do. Narcolepsy causes not only excessive daytime sleepiness, but interrupted sleep and wake cycles. Sleep is typically not restorative, and may be disturbed by parasomnias such as sleep paralysis and hallucinations.
Narcolepsy sufferers may feel overwhelming exhaustion during the day, but be unable to sleep at night, or unable to fall back to sleep after waking. This is typically due to what’s known as disrupted nighttime sleep, or DNS. (12)
DNS differs from classic insomnia in that narcolepsy patients don’t usually have difficulty with falling asleep, but frequently contend with disrupted sleep and middle insomnia in addition to typical narcolepsy symptoms. DNS can be part of the constellation of symptoms associated with narcolepsy, leading to periods of poor sleep despite the amount of time sufferers must spend in bed.
Health Consequences of Insomnia
While the occasional bout with insomnia symptoms may be difficult to avoid, insomnia that lasts more than a few weeks or becomes chronic may have serious health effects. Insomnia may lead to long-term sleep debt, which can result in disruptions to metabolism, mood, and glucose tolerance.
The possible health consequences of insomnia include the following:
- Impaired immune function
- Increased risk of chronic disease including diabetes, heart disease, and hypertension
- Increased risk of mood disorders such as anxiety and depression
- Difficulty concentrating
- Difficulty retaining new information
- Impaired judgment, reasoning, and problem-solving abilities
- Impaired performance at work or school
- Increased risk of errors and accidents, due partly to impaired reaction times
- Diminished sex drive and fertility
- Increased signs of aging, especially in the skin
- Increased risk of weight gain
- Reduced life expectancy
Though hyperarousal of the central nervous system in chronic insomnia may help the body overcome some of these cognitive and physical impacts of insomnia, at least 40% of long-term insomnia sufferers report feeling some daytime effects of insomnia disorder.
Insomnia’s Link to Depression and Anxiety
Anxiety and psychiatric disorders are a leading cause of insomnia symptoms. The inability to sleep is a common sign of many mood disturbances, including:
- Depression. Difficulty sleeping may be one of the first symptoms of depression. In fact, there is evidence to suggest that acute insomnia is frequently related to the first onset of depression symptoms (13)
- Social phobia
- Both the depressive and manic phases of bipolar disorder. Lack of sleep due to jet lag or other reasons may be the catalyst for a manic episode, and persist once the episode has begun
- Post-traumatic stress disorder. Disrupted sleep and nightmares are common symptoms of post-traumatic stress disorder. Fear, hypervigilance, and paranoia may make sleep difficult or impossible. Insomnia may be caused by flashbacks, as well as hallucinations and talking or shouting during sleep. PTSD sufferers may also be awakened from sleep by movements such as kicking or punching
Medications to treat psychiatric disturbances may also cause insomnia. Psychotropic medications may have stimulating effects that contribute to interrupted sleep. Restless leg syndrome and periodic limb movements may be triggered or exacerbated by antidepressants and other drugs used to treat mood disorders.
Which Came First, the Mood Disorder or the Insomnia Symptoms?
It was once thought that insomnia symptoms resulted from psychiatric disorders and depression, not the other way around. Now the evidence isn’t so clear. Sleep problems may not just be the result of emotional disturbances, they may increase the likelihood of suffering from them, as well. (14)
An analysis of major studies revealed that study subjects who suffered from insomnia symptoms were twice as likely to be diagnosed with depression as those without sleep difficulties. (15)
Why? Though the connection between mood disorders and insomnia isn’t entirely clear, it is well-known that hormones and neurotransmitters are affected by disturbances in sleep. Sleep is a restorative activity that reduces stress in the body and particular areas of the brain, especially the axis between the hypothalamus and adrenal and pituitary glands. Excess secretion of cortisol — also known as “the stress hormone” — may play a role, as well.
Lack of sleep and the resulting physiological stress may predispose sufferers of insomnia symptoms to major mood disturbances, making early treatment of chronic insomnia and other sleep disorders essential, especially in people with a family history of psychiatric disorders or sleep difficulties. (16)
Insomnia Fact: Some insomniacs suffer from what’s known as somniphobia, the fear of sleep. Symptoms typically include extreme dread of going to sleep, as well as anxiety, feelings of panic, and shortness of breath
Insomnia Myths Vs. Reality
Myth: Insomnia only happens to anxious people
Reality: Insomnia symptoms can happen for a vast number of reasons. While anxiety is a common cause, it’s only one of many factors that can provoke this sleep disorder.
Myth: Insomnia is just the inability to fall asleep
Reality: Insomnia might involve the inability to fall asleep, or manifest as frequently waking during the night, waking early, or feeling sleepy during the day. Someone who can fall asleep quickly may still be diagnosed with insomnia if they can’t remain asleep, wake too early, or suffer from fragmented, low-quality sleep.
Myth: If you can’t fall asleep, you should lie in bed until you do
Reality: Remaining in bed when you can’t sleep may signal to your brain that your sleeping environment is where you lie awake. It may also heighten anxiety, making it harder to doze off again. Most experts agree that if you don’t fall back to sleep within 15 or 20 minutes of waking up, it’s best to get out of bed and participate in a relaxing activity such as listening to soothing music or reading.
Myth: Alcohol and television can help combat insomnia symptoms
Reality: Alcohol has been proven to impair sleep quality and increase the risk of waking during the night. Watching television — the news in particular — can be stressful, making relaxation more difficult. Additionally, TVs, smartphones, and computers emit the blue light well-known for interfering with sleep-wake cycles. (17)
Myth: If you awaken for only short periods during the night, it won’t affect the quality of your sleep
Reality: A brief slumber disruption may not seem particularly important, but waking up for any amount of time during the night can cause more than a few lost minutes of rest. In fact, studies suggest interrupted sleep is just as bad for you as insufficient sleep. (18)
Insomnia Fact: Parents lose an average of 44 days of sleep in the first year after a baby is born
How to Cure Insomnia
The cure for insomnia may not be as simple as taking a pill or counting sheep, but effective treatments do exist. Remedies for insomnia symptoms often differ from those for insomnia disorder. Possible treatments for mild or short-term insomnia symptoms include the following:
- For those suffering from insomnia caused by a medical condition, address the underlying cause. For example, if trouble sleeping is partly the result of asthma symptoms, a more effective asthma treatment plan may reduce or eliminate insomnia
- Lifestyle changes. Exercising regularly, eating well, avoiding alcohol and stimulants, eliminating nicotine, and creating a relaxing bedtime routine can all help promote high-quality sleep
- Sunlight exposure. Getting plenty of exposure to daylight, especially in the morning, helps maintain the body’s natural circadian rhythms, which are responsible for maintaining a consistent sleep-wake schedule
- Psychotherapy can help insomnia sufferers address anxiety and other thought patterns that might make sleep more challenging. Awareness of negative thoughts and habits can short-circuit sleep difficulties and make relaxing easier
- Medications and supplements. Your doctor may recommend a short-term course of prescription sleeping pills or other sleep aids, including melatonin and antihistamines
How to End Chronic Insomnia
Though it may contradict much of what we’ve heard about treating insomnia, good sleep hygiene is often not an effective treatment for chronic insomnia.
Good sleep hygiene can help with less persistent sleep difficulties, but is not a first-line treatment for insomnia disorder.
What does help? Paradoxically, one of the most effective chronic insomnia treatments is reducing the number of hours spent in bed. This type of treatment is part of the Cognitive Behavior Therapy protocol for chronic insomnia. This protocol includes:
1. Sleep restriction. Sleep restriction requires limiting the time spent in bed to the number of hours typically spent asleep. For example, if you usually spend eight hours in bed but lie awake for two, sleep restriction therapy might require you to go to bed at midnight and get up at 6 am. Going to bed later is usually recommended during this type of treatment, rather than getting up earlier than your normal time.
Though it may seem to compound the problem of insomnia, sleep restriction therapy increases sleep efficiency and cuts down on waking during the night. Once someone undergoing training is sleeping well for six hours without waking, 15-minute blocks may be added to the time spent in bed, increasing gradually until the person feels rested during the day.
2. Stimulus control training. This helps chronic insomnia sufferers reduce negative associations with sleep and the bedroom environment. Training essentials include:
- Lying down in bed only when sleepy
- Using the bed only for sleep and sex
- Getting up after 20 minutes if you can’t fall asleep, returning to bed only when sleepy and repeating if necessary
- Getting up at the same time every morning
- Foregoing naps
This type of therapy protocol can train the brain to associate a particular environment and time of night with sleep, and break the conditioning that causes delayed, fragmented, or low-quality sleep.
3. Relaxation training. This type of training teaches insomnia sufferers to use a combination of meditation techniques, guided imagery, and breathing exercises to prepare the body for sleep. Biofeedback helps patients learn to control the body’s normally involuntary bodily processes, such as heart rate, blood pressure, and muscle tension. This combination of techniques helps to relax the body, calm the mind, and make falling asleep easier.
4. Psychotherapy. This aspect of the protocol involves challenging negative beliefs about sleep, and replacing fearful associations with positive thinking. Worrying may be relegated to a particular time of day so the evening and just before bed become times of relaxation. Insomnia patients in cognitive behavior therapy learn to manage stress and control the over-active thought process that may lead to sleep difficulties.
Sleep Hygiene — A Good Start for Mild Insomnia
Though it’s rarely effective for chronic insomnia, good sleep hygiene may help with less severe and persistent insomnia symptoms.
Good sleep hygiene basics include:
- Maintaining a regular sleep-wake schedule
- Using the bed only for sleep and sex
- Avoiding the blue light exposure from electronics and smart phones in the hours leading up to bed
- Ensuring that your bedroom stays cool, dark, and quiet
- Investing in a comfortable mattress and bedding
Insomnia may be common, but it doesn’t have to be chronic. Addressing the problem early, treating underlying conditions, and practicing healthy, sleep-promoting habits may be all that’s needed to return to deep, restorative slumber.
- Swapna Bhaskar, Prevalence of Chronic Insomnia in Adult Patients and Its Correlation with Medical Comorbidities. Journal of Family Medicine and Primary Care, Oct. 2016
- Y. Ustinov, Association Between Report of Insomnia and Daytime Functioning, January 11, 2010, Sleep Medicine
- Paula Alhola, Sleep Deprivation: Impact on Cognitive Performance, October 3, 2007, Neuropsychiatric Disease and Treatment
- Bonnet MH and Arand DL. Hyperarousal and Insomnia: State of the Science. – PubMed – NCBI, Feb. 14, 2010
- Eric Nofzinger, MD, Functional Neuroimaging Evidence for Hyperarousal in Insomnia, January 28, 2015, American Journal of Psychiatry
- Rachel E. Salas, Increased Use-Dependent Plasticity in Chronic Insomnia. March 1, 2014, PubMed Central
- Mahesh M. Thakkar, Alcohol Disrupts Sleep Homeostasis, June 1, 21015, PubMed Central
- Sleep Patterns and Insomnia Among Adolescents: a Population-Based Study, Mari Hysing and Stale Pallesen, Marc 8, 2013, European Sleep Research Society
- Sharon Schutte-Rodin, M.D., Lauren Broch, Ph.D, Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults, Journal of Clinical Sleep Medicine – Research & Review Articles in Sleep Medicine, July 2008
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- Thomas Roth, Disrupted Nighttime Sleep in Narcolepsy, September 9, 2013, Journal of Clinical Sleep Medicine
- Jason G. Ellis, PhD. The Natural History of Insomnia: Acute Insomnia and First-onset Depression. Sleep, January 1, 2014
- D. Neckelmann, Chronic Insomnia As a Risk Factor for Developing Anxiety and Depression, July 30, 2007, PubMed Central
- L. Li, C. Wu, Insomnia and the Risk of Depression: a Meta-analysis of Prospective Cohort Studies. November 6, 2016, PubMed Central
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- West KE , et al. “Blue Light from Light-emitting Diodes Elicits a Dose-dependent Suppression of Melatonin in Humans, PubMed, National Center for Biotechnology Information
- Goran Medic, Short and Long-term Health Consequences of Sleep Disruption, May 19, 2017, Nature and Science of Sleep
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