Insomnia

What Is It?

Insomnia is difficulty getting enough sleep or trouble sleeping without interruption. You may have difficulty falling asleep, may wake up too early, or may wake up periodically during the night. Insomnia of any kind can keep you from feeling rested and refreshed during the day. Almost all of us have episodes of insomnia at some time, but insomnia is not a short-term problem for everyone. Insomnia is classified as chronic when it happens almost every night for at least one month. Insomnia can be related to a medical or psychiatric illness, can be caused by mental stress or excitement, or can be caused by your daytime and bedtime habits.

Your habits and surroundings are the usual causes of short-term insomnia problems. Factors that contribute to insomnia can include:

• Stress or anxiety
• A change in sleeping environment (being a guest at a hotel or a relative's home)
• An uncomfortable sleeping environment (too hot, too cold, too bright, too noisy)
• An uncomfortable mattress
• Pajamas that are too tight
• Having a bed partner who snores or has disruptive sleep patterns
• Watching television, reading a book or problem-solving in your bed, so your brain associates lying down in bed without activities other than sleeping
• Eating a heavy meal before bedtime
• Taking a prescription medication that has insomnia as a side effect
• Drinking alcoholic beverages before bedtime
• Having a high intake of beverages containing caffeine (coffee, tea, cola) during the day
• Cigarette smoking
• Exercising immediately before bedtime
• Not exercising enough during the day, so you have energy to spare
• Taking a hot bath or shower before bed
• Traveling to a different time zone
• Traveling to a much higher altitude
• Shift work

Pregnant women are particularly vulnerable to insomnia. Women who are pregnant may have insomnia because of hormone changes, heartburn, leg cramps or a need to urinate more frequently. In addition, the unborn baby's increasing size often makes it harder for the mother to find a comfortable sleeping position.

Chronic insomnia may be caused by a medical or psychiatric problem. Some common causes of chronic insomnia include:

• Psychiatric illness, especially depression or post-traumatic stress disorder (PTSD)
• Chronic medical illnesses, especially kidney disease, heart failure or asthma
• Painful illnesses, especially arthritis, neuropathy, acid reflux or cancer
• Hormone imbalance, especially menopause or hyperthyroidism
• Taking a precription medicine that has insomnia as a side effect
• Obstructive sleep apnea Snorers or people who are overweight may have repeated episodes in which breathing stops for 10 seconds to 30 seconds during sleep, just when the person is relaxing into deep sleep. Sleep apnea is caused most often by relaxing the tongue and throat tissues, which can settle into a position that closes your airway. Your body reacts to sleep apnea by releasing adrenaline-like "alarm" hormones so you will awaken and resume breathing. These hormones keep you awake for periods of the night, and can cause high blood pressure that lasts through the day.
• Narcolepsy In this condition, the patient's sleep is disturbed at night, but he or she falls asleep suddenly and involuntarily during the daytime
• Restless legs syndrome This disorder causes uncomfortable sensations in the legs. Symptoms can include twitching of the legs, a habit of repetitive leg movements, and leg cramps.

An estimated 25% to 33% of people in the United States have some form of insomnia. Sleeping pills are usually not the best way to correct an insomnia problem, but they are among the most prescribed medicines in the United States. Women are affected more often than men, especially women older than age 60.

Symptoms

Symptoms of insomnia can include:

• Difficulty falling asleep
• Waking up periodically during the night
• Waking up in the early morning, but not feeling rested
• Feeling tired and irritable during the day
• Having trouble concentrating

Diagnosis

Your doctor often can determine the cause of your insomnia by asking about your habits and sleep environment, by reviewing your symptoms, and by examining you. Your doctor may suggest that you keep a sleep diary (a log of your sleep patterns) to provide an exact record of how many hours you sleep, whether symptoms may be your trigger for awakenings, and at what times you wake up. If your doctor suspects that a medical illness is causing your insomnia, you may need additional tests. In some patients, an overnight sleep study at a sleep clinic may be necessary. During a sleep study, your brain waves, breathing pattern and oxygen levels can be monitored, and your body movements can be observed.

Expected Duration

Insomnia may last only one or two nights, or it may continue for weeks, months or years. How long insomnia lasts depends on its cause, and on the success of lifestyle changes and treatment.

Prevention

It helps to have habits that promote healthy sleep:

• Follow a regular sleep schedule. Have a routine bedtime and wake up at roughly the same hour each morning.
• Sleep in loose, comfortable clothes in a comfortable bed.
• Eliminate any sources of noise or bright lights that prevent or disrupt sleep. If noise from outside your bedroom can't be eliminated, it might help if you drown out that noise by creating a monotonous noise of your own. Use a fan, a channel with static noise on your radio, or a recording of ocean waves to make a noise that can lull you to sleep.
• Maintain a comfortable temperature in your bedroom
• Cut down on beverages containing caffeine during the day, since the stimulating effects of caffeine can last for many hours
• Avoid heavy meals before bedtime
• Eliminate alcohol, since many people experience wakefulness as the effect of the alcohol wears off
• Exercise daily
• If you read before bed, do this in a chair or in another room
• Consider sleeping in a separate bed or separate room if your partner keeps you awake

If you have chronic insomnia because of chronic pain, medical illness or psychiatric problems, seek prompt treatment for your health problem. Don't assume that insomnia is an unavoidable part of your illness.

Treatment

Changes in your bedtime surroundings and habits that can promote sleep are usually the most important way to manage insomnia.

Behavioral therapies also may be used to treat some patients with insomnia. These therapies include:

• Relaxation therapy Special techniques to quiet the mind and relax the muscles
• Sleep restriction A program that at first permits only a few hours of sleep per night, then gradually increases the nightly sleeping time
• Reconditioning A program that teaches the patient to associate the bed only with sleeping (and sexual activity) by having the patient go to bed only when sleepy and avoid daytime naps

If you are found to have a medical problem, a mental health problem or a sleep disorder (such as sleep apnea), then specific treatment is important. Medications are available to treat narcolepsy and restless legs syndrome. Special masks can be used to help patients with sleep apnea breathe better.

Your doctor may prescribe a short-acting sleep medication for a few days, especially if insomnia is seriously interfering with your ability to function during the day. Newer sleeping pills, including zolpidem (Ambien), zaleplon (Sonata) and eszopiclone (Lunesta) appear to be safer and potentially more helpful medicines than other sleeping pills.

Other sleeping pills are not generally helpful for long-term use, although many people use them. Antihistamines such as diphenhydramine (Benadryl and Tylenol PM) and doxylamine (Unisom) cause daytime drowsiness in many people. Treatment for longer than two weeks with trazodone (Desyrel) has not helped insomnia in studies of this medicine. Sedative drugs such as diazepam (Valium), triazolam (Halcion), lorazepam (Ativan), estazolam (ProSom), and temazepam (Restoril) are potentially addictive medicines, may require increasing doses to continue to have a treatment effect, and can cause insomnia as a withdrawal symptom after they are stopped. Melatonin, a dietary supplement, hardly had any effect on people in small studies who took it for treatment of insomnia.

When To Call A Professional

Call your doctor if you are worried about sleeping problems, especially if insufficient sleep or disturbed sleep is interfering with your ability to function normally during the day. Insomnia is an urgent medical problem if sleep problems are making it unsafe for you to drive a car or to perform potentially dangerous tasks at work.

Prognosis

In many people with insomnia, normal sleep patterns return within a few days, especially if a lifestyle issue (stress, a habit of heavy meals before bed, a change in time zones) disappears or is modified.

In people with chronic insomnia, the outlook depends on the underlying problem. In people with obstructive sleep apnea, 80% experience relief when they use a nighttime nose mask that provides modest continuous air pressure through the mouth and nose. This mask must be prescribed by a doctor.

Additional Info

National Center on Sleep Disorders Research

National Institutes of Health

6705 Rockledge Drive

One Rockledge Centre, Suite 6022

Bethesda, MD 20892-7993

Phone: (301) 435-0199

Fax: (301) 480-3451

E-Mail: ncsdr@nih.gov

http://www.nhlbi.nih.gov/about/ncsdr/