Insomnia

Topic Overview

What is insomnia?

Insomnia is a common sleep problem that can affect your quality of life. People with insomnia have trouble falling asleep or staying asleep. They may wake up during the night or wake up too early the next morning.

Your sleep problems may come and go, or they may be ongoing.

• A short-term sleep problem is often linked to short-term stress. This short-term insomnia can last for days to weeks. It often gets better in less than a month.
• A chronic sleep problem is ongoing. This is called chronic insomnia. It is often a symptom of another health problem, such as depression or chronic pain. Chronic insomnia is less common than short-term sleep problems.

What causes insomnia?

There are many things that can cause sleep problems. Insomnia may be caused by:

• Stress. Stress can be caused by fear about a single event, such as giving a speech. Or you may have ongoing stress, such as worry about work or school.
• Depression, anxiety, and other mental or emotional conditions.
• Poor sleep habits, such as watching TV in bed or not having a regular bedtime schedule. If you have trouble sleeping, you may worry about being able to fall asleep. This can make the problem worse.
• Changes in your sleep habits or surroundings. This includes changes that happen where you sleep, such as noise, light, or sleeping in a different bed. It also includes changes in your sleep pattern, such as having jet lag or working a late shift.
• Other health problems, such as pain, breathing problems, and restless legs syndrome.
• Stimulants, such as tobacco and caffeine, as well as certain medicines, alcohol, and drugs.
• Lack of regular exercise.¹

What are the symptoms?

The symptoms of insomnia are different for each person. People with insomnia may:

• Have trouble falling asleep. This can mean lying in bed for up to an hour or more, tossing and turning, waiting to fall asleep.
• Wake up during the night and have trouble going back to sleep.
• Wake up too early in the morning.
• Feel tired when they wake up, like they didn't get enough sleep.
• Feel grouchy, sleepy, or anxious, and be unable to get things done during the daytime.

How is insomnia diagnosed?

Insomnia is not a disease, and no test can diagnose it. But when you can't sleep well, it often has to do with some other cause. Your doctor will probably assess your current health and ask about any health problems you have had and any medicines you are taking.

Sometimes a doctor will do a physical exam, blood tests, and, in some cases, sleep studies to help find out if you have a health problem that may be causing the insomnia.

Your doctor may also ask about your sleep history—how well you sleep, how long you sleep, your bedtime habits, and any unusual behaviors you may have. Your doctor may ask you to keep a sleep diary, which is a record of your sleep patterns, for a week or two. He or she may recommend a counselor if your symptoms point to a mental health problem, such as depression or anxiety.

How is it treated?

Treatment for insomnia focuses on the reason why you don't sleep well. If you have a medical problem, such as chronic pain, or an emotional problem, such as stress, treating that problem may help you sleep better. You may be able to sleep better by making some small changes. It may help to:

• Go to bed at the same time each night.
• Get up at the same time each day.
• Avoid caffeine and alcohol for several hours before bedtime.
• Get regular exercise (but make sure you finish the exercise at least 3 to 4 hours before you go to bed).
• Avoid daytime naps.

Some people may need medicine for a while to help them fall asleep. Doctors often prescribe medicine for a short time if other treatment isn't working. But medicine doesn't work as well over time as lifestyle and behavior changes do.² Sleep medicine can also become habit-forming. Medicine works best as a short-term treatment combined with lifestyle and behavior changes.

Your doctor may also recommend counseling, which can help you learn new habits that may help you sleep better.

Talk to your doctor about your sleep problems and any other health issues you may have. This is important, because lack of sleep can lead to depression, accidents, problems at work, marital and social problems, drinking more alcohol than usual, and poor health. Treatment may help you avoid these problems and feel better.

Frequently Asked Questions

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	Decision Points focus on key medical care decisions that are important to many health problems.
	Insomnia: Should I take sleeping pills?
	Actionsets are designed to help people take an active role in managing a health condition.
	Insomnia: Improving your sleep
	RLS: Getting more sleep
	Sleep problems: Dealing with jet lag
	Stress management: Breathing exercises for relaxation
	Stress management: Doing guided imagery to relax
	Stress management: Doing meditation
	Stress management: Doing progressive muscle relaxation
	Stress management: Relaxing your mind and body

Symptoms

Each person experiences insomnia differently. People with insomnia may:

• Have trouble falling asleep. This can mean lying in bed for up to an hour or more, tossing and turning, waiting to fall asleep.
• Wake up and have trouble falling back to sleep.
• Wake up too early in the morning.
• Feel tired when they wake up, like they didn't get enough sleep.
• Feel grouchy, sleepy, or anxious, and be unable to get things done during the daytime.

One Man's Story: “When I wake up at 2 or 3 in the morning, my mind starts processing stuff—things that I need to get done, that I forgot to do. Trying to relieve that anxiety seems to me a very worthwhile sleep prescription.”—Cort, 64 Read more about Cort and how he learned to cope with insomnia.

Quality versus quantity of sleep

The quality of their day is what makes people with insomnia different from people who generally sleep fewer hours or who have a different sleep disorder. With insomnia, you sleep so badly that you feel grouchy and perform poorly during the day. But it is possible to be a restless sleeper or to sleep less than 8 hours a night and yet get the amount of sleep you need. If you wake up refreshed with energy and are able to get things done during the day, then you are probably getting enough sleep.

Not getting enough sleep can affect your quality of life. It can lead to serious problems including injury, accidents, anxiety, and depression. Talk with your doctor if you think that you have insomnia.

Exams and Tests

Insomnia is not a disease, and no specific test can diagnose it. But it can make you feel bad, and it can affect your health. It can also be a sign of other problems. Your doctor may want to do blood tests to rule out certain medical conditions such as thyroid problems. "Normal sleep" differs for each person. Checking your health and sleep history is an important first step to finding a cause for poor-quality sleep. Talk with your doctor about your medical history and any medical problems you have or any medicines you are taking.

• Your doctor can learn a lot about your insomnia and its causes by reviewing your sleep history. He or she may also ask you to keep a sleep diary (What is a PDF document?) for 1 or 2 weeks to track your sleep patterns and habits. Your sleep diary can help your doctor spot certain habits that may affect your sleep, or even see signs of a hidden health problem that may need to be checked out.
• If your symptoms point to mental health concerns, such as depression or anxiety, you may be referred to a mental health professional.

Sleep studies

If your doctor thinks that you have a sleep disorder, he or she may refer you for a sleep study. When you have a sleep study, you stay overnight in a special sleep lab.

Your doctor may recommend a sleep study if your insomnia seems to be caused by breathing problems (such as sleep apnea) or periodic limb movement disorder, or if you have tried other treatment that hasn't worked.³

Sleep studies are not helpful for insomnia caused by mental health problems, fibromyalgia, or chronic fatigue syndrome.³

Treatment Overview

Tossing and turning during the night or having trouble falling asleep can make you sleepy and grouchy during the day. You may have tried some things to help your insomnia that haven't worked. The good news is that there are many treatments to help you sleep better. But first it helps to know the reason why you don't sleep well. If you have a medical problem, such as chronic pain, or an emotional problem, such as stress or depression, treating that problem may help you sleep better.

Treatment options for insomnia

Treatment options include behavior and lifestyle changes, medicines, and complementary medicines.

Behavior and lifestyle changes

Getting ready for bed means more than turning down the sheets. Sleep experts know that there are many things that affect how well you sleep. And research shows that, compared to using medicines, behavior changes improve overall sleep quality and the time it takes to fall asleep, without any side effects.² Perhaps most important, these improvements last over time.

To improve your sleep, here are some things you can try:

• Relaxation exercises,such as progressive muscle relaxation, may help you if you lie in bed with your mind racing. Try these relaxation exercises:

  Breathing exercises for relaxation

  Doing guided imagery to relax

  Doing meditation

  Doing progressive muscle relaxation

  Relaxing your mind and body

• Positive thinking with cognitive-behavioral therapy. Positive thinking, or healthy thinking, is a way to help you stay well or cope with a health problem by changing how you think. Cognitive-behavioral therapy is a type of counseling that can help you understand why you have sleep problems and can show you how to deal with them. Research shows that cognitive-behavioral therapy helps reduce interrupted sleep over time.⁴
• Lifestyle changes are simple things you can do that may help you sleep better. These include changing your sleep area or schedule, watching what and when you eat and drink, and being more active. It's also important to keep regular bedtimes and wake times—7 days a week—and to try to avoid taking naps during the day. For more information, see:

  Insomnia: Improving your sleep.

Medicines

In some cases, taking sleeping pills for a short time helps you get some rest, while behavior and lifestyle changes can help you over the long term. Doctors recommend taking sleep medicines only now and then or only for a short time. They are not the first choice for treating chronic insomnia.

This advice about medicines applies to everyone, but especially to older adults. This is because while anyone can become dependent on sleep medicines, these medicines can affect how well older people think during and after long-term use.⁵

Many sleep medicines cause side effects, such as low blood pressure, anxiety, and nausea. These medicines also may become less effective when your body gets used to them and may cause withdrawal symptoms when you stop using them.

Sleep medicines include:

• Prescription sleep medicines, such as eszopiclone (Lunesta), ramelteon (Rozerem), zaleplon (Sonata), and zolpidem (Ambien). They are the first-choice medicines for short-term insomnia.⁶
• Benzodiazepines, such as quazepam (Doral), diazepam (such as Valium), and lorazepam (Ativan). These medicines help you fall asleep or stay asleep. You need a prescription for these medicines.
• Antidepressants that have a calming or sedative effect. These can be used to help you sleep.
• Antihistamines. Typically used for allergies, these can provide short-term relief of sleeplessness.
• Nonprescription medicines for sleep. These can help, but they also can cause side effects, such as drowsiness the next day. Over time, sleeping pills may not work as well as they did when you first started using them.

To help you decide if you should use sleeping pills to treat insomnia, see:

Should I take sleeping pills for insomnia?

One Man's Story: While Cort does have a prescription for sleeping pills, he uses the medicine only when he needs to be well rested the next day, such as when he has to give a presentation at work. Cort heeds his doctor’s warning about becoming dependent on sleeping pills. “I have a prescription for 5 mg tablets, and I never take a full one. I break them in half, and I never take them more than once in 2 weeks.” —Cort, 64 Read more about Cort and how he learned to cope with insomnia.

Complementary medicine

Other treatments for insomnia may include complementary and alternative medicines. Two of the most popular alternative medicines are:

• Valerian, an herbal sleep remedy. Valerian appears to be safe, and it may improve sleep when taken for a week or two.⁷
• Melatonin, a hormone produced by the brain. You can also buy it as a supplement. Melatonin has also been used to treat jet lag and poor sleep from working the night shift.

Don't rely on alcohol

Some people use alcohol to help them sleep, but that's not a good idea. At first, drinking alcohol may make you sleepy and help you fall asleep. But when you drink alcohol, you are more likely to wake up later in the night and have a hard time falling back asleep. This can leave you feeling tired the next day.

Home Treatment

After you and your doctor have treated any health problems related to your insomnia, there are many steps you can take to improve your sleep. Here are few examples:

• Avoid or limit caffeine, nicotine, and alcohol. Don't use them at all late in the day or in the evening.
• Check all of your medicines with your doctor to see if they could be affecting your sleep. To help avoid sleep problems, you may be able to adjust your dose or change the time of day you take your medicine.
• Use the evening hours for settling down.
• Make exercise a regular part of your life, but don't do it within 3 to 4 hours of bedtime.
• Keep your bedroom quiet, dark, and cool. Try using a sleep mask and earplugs to help you sleep.

For more tips on how to improve your sleep, see:

Insomnia: Improving your sleep.

Sleep problems: Dealing with jet lag.

Shift Work Sleep Disorder.

Sleep tips for older adults

Older adults, especially those living in nursing homes or who are cared for by others, often have ongoing sleep problems. It's natural for your sleep patterns to change as you get older, but it doesn't mean that you need less sleep or that the sleep you do get is enough.

There are things you can do to cope with changing sleep patterns as you get older, such as having familiar evening and nighttime routines.

Treatment if sleep problems don't get better

Be sure to talk to your doctor if your sleep problem gets worse, if it lasts for more than 2 weeks, or if your symptoms become more severe or happen more often.

Other Places To Get Help

Organizations

Related Information

• Melatonin
• Sleep Apnea
• Sleep Problems, Age 12 and Older
• Sleep Studies

References

Citations

1. Morgan K (2003). Daytime activity and risk factors for late-life insomnia. Journal of Sleep Research, 12(3): 231–238.
2. Smith MT, et al. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159(1): 5–11.
3. Littner M, et al. (2003). Practice parameters for using polysomnography to evaluate insomnia: An update. Sleep, 26(6): 754–760.
4. Edinger JD, et al. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. JAMA, 285(14): 1856–1864.
5. Holbrook AM, et al. (2000). The diagnosis and management of insomnia in clinical practice: A practical evidence-based approach. Canadian Medican Association Journal, 162(2): 216–220.
6. Estivill E, et al. (2003). Consensus on drug treatment, definition, and diagnosis for insomnia. Clinical Drug Investigations, 23(6): 351–385.
7. Hadley S, Petry J (2003). Valerian. American Family Physician, 67(8): 1755–1758.

Other Works Consulted

• Holbrook AM, et al. (2000). Meta-analysis of benzodiazepine use in the treatment of insomnia. Canadian Medical Association Journal, 162(2): 225–233.
• Chesson A Jr, et al. (2000). Practice parameters for the evaluation of chronic insomnia. Sleep, 22(8): 1128–1133.
• Lippmann S, et al. (2001). Insomnia: Therapeutic approach. Southern Medical Journal, 94(9): 866–893.
• Ropper AH, Brown RH (2005). Sleep and its abnormalities. In Adams and Victor's Principles of Neurology, 8th ed., pp. 333–351. New York: McGraw-Hill.

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