Insomnia – Causes, Symptoms, Diagnosis, and Treatments

Insomnia or sleeplessness is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or both, or cause you to wake up too early and not be able to get back to sleep.

It affects millions of people across the world. The National Institute of Health estimates that nearly 30% of world population suffers sleep disruption and nearly 10% among them have daytime sleeping.

What is Insomnia?

Insomnia can impair psychosocial functioning and quality of life. Getting enough sleep is an important aspect of healthy lifestyle. An adult person needs at least 7 to 8 hours of sleep in a day. However, sleep patterns change with age. For instance, older adults may sleep less at night and take frequent naps during the day. Lack of sleep makes a person feel tired, depressed, and irritable. It also decreases concentration and reduces the ability of a person to perform his or her daily activities. Insomnia is associated with mood swings, irritability, and anxiety. It also increases the blood pressure and risk of chronic diseases such as diabetes.

Every person experiences occasional episodes of insomnia that come and go without causing any serious problems. But, for some people, the episodes of insomnia last for months or years and have a significant impact on the quality of life.

Insomnia is primarily diagnosed based on the sleep history of a patient. Polysomnography is a type of sleep study, which is performed only in patients with sleep disorders such as periodic limb movement disorder (PLMB) or obstructive sleep apnea (OSA). The treatment for insomnia includes a combination of medications, behavioral or psychological therapies, and lifestyle modification.

Insomnia is often caused due to an underlying disease or condition. Some of the most common causes of insomnia are:

• Pain: Acute physical pain such as a toothache, abdominal pain and so on causes sleep disturbance until the inflammation and pain subside.
• Poor Eating Habits: Overeating or eating a big meal late at night impairs metabolism. It also disrupts the sleep-wake cycle and causes insomnia.
• Travel and Jet Lag: Traveling from one time zone to another alters the body’s normal circadian rhythm and causes temporary insomnia.
• Changes in Work Shift: Changes in work shift causes short-term insomnia in some people as they need time to re-adjust their body clock.
• Stress: Some people fret or worry about insignificant matters and lose sleep. However, it is natural to worry over a recent event or an unexpected incident, but it should not affect the quality and quantity of sleep.
• Anxiety and Depression: Anxiety or depression affects sleep and causes insomnia.
• Biological Causes: Biological changes such as aging affect the sleep pattern. Older people tend to have lighter sleep and wake up more often in the night.
• Hormonal Changes: Hormonal imbalances cause difficulty in sleeping especially in the females during pregnancy and menopause. These changes are usually caused due to changes in the estrogen levels.

Medical Conditions

Certain medical conditions that interfere with sleep are:

• Asthma
• Arthritis
• Heartburn
• Hyperglycemia
• Hyperthyroidism
• Prostate disease
• Angina or chest pain
• Congestive heart failure
• Chronic fatigue syndrome
• Hypoglycemia due to diabetes
• Chronic obstructive pulmonary disease
• Acid reflux or gastroesophageal reflux disease
• Restless leg syndrome: Restless leg syndrome is a disease of the nervous system characterized by an unpleasant or burning sensation in the legs. It causes the individual to move the legs unnecessarily. The unpleasant sensation may keep the person aroused from sleep.
• Sleep Apnea: Sleep apnea is associated with difficulty in breathing while sleeping. It causes awakening in the middle of sleep.
• Medications: Medications such as antidepressants, anti-hypertensives, and anti-asthma drugs can interfere with sleep and cause insomnia.
• Excess intake of caffeine, nicotine, and alcohol: Caffeine and nicotine act as central nervous system stimulants. Consuming the products rich in caffeine and nicotine late in the evening disrupts sleep and causes insomnia. Alcohol often causes an awakening in the middle of the night by preventing deeper stages of sleep. However, the effect of these substances varies from one person to another.
• Lack of physical activity: Lack of physical or social activity can cause insomnia.

Types of Insomnia

• Acute Insomnia: It is characterized by a brief episode of difficulty in sleeping caused due to stressful events in life or due to depression. It often resolves without any treatment.
• Chronic Insomnia: It is a long-standing sleep disorder characterized by trouble falling asleep or staying asleep at least three nights per week for three months or longer. It may be caused due to a long-term history of sleeping disorders.
• Comorbid Insomnia: It is caused due to other medical condition such as arthritis or back pain, which makes it difficult to sleep.
• Onset Insomnia: It is characterized by difficulty falling asleep at the beginning of night.
• Maintenance Insomnia: It is characterized by an inability to stay asleep. People with maintenance insomnia wake up during the night and have difficulty returning to sleep.

Insomnia itself is considered as a symptom of other medical conditions such as chronic anxiety or depression.

Some of the common complaints associated with insomnia are:

• Difficulty maintaining sleep
• Trouble falling asleep at night
• Tending to fall asleep during the day
• Feeling tired and lethargic during the day
• Waking up not feeling recharged or refreshed
• Feeling weak or tired even after a night of sleep
• Awakening relatively earlier than the desired time
• Nighttime awakenings or waking up several times at night

Complications of Insomnia

• Heart disease
• Tension headaches
• Low energy levels
• The decrease in attention span
• Poor memory and recall
• Poor focus and concentration
• Lack of coordination and errors
• Lack of proper motivation
• Poor performance at work or in school
• Inability to perform simple daily tasks
• Difficulty socializing with others
• Low immune functions
• Constant worrying and fretting
• Signs of gastrointestinal problems
• Anxiety and depression
• Feelings of moodiness and irritability

• Age: The elderly have a higher risk for insomnia due to lifestyle changes such as lack of physical activity, increased health problems, and increased use of medications. The body clocks of older people are disturbed and this may interfere with their desired sleep time. In general, older individuals have lesser deep sleep, more sleep fragmentation, and use a large number of medications, all of which increases the risk of insomnia.
• Gender: Women are at a higher risk for insomnia than men due to hormonal changes occurring during puberty, pregnancy, postpartum period, or during the menopausal transition and after menopause.
• Lifestyle Changes: Poor lifestyle such as engaging in shift work, smoking or using other tobacco products, alcohol consumption or drinking beverages containing caffeine in the afternoon or evening, and exercising close to bedtime impairs sleep habits and increases the risk of insomnia.
• Medications: Medications such as steroids, theophylline, phenytoin, levodopa, and selective serotonin reuptake inhibitors increase the risk of insomnia.
• Mental Health Conditions: Patients with depression, substance abuse, anxiety, and other medical conditions such as heart disease, musculoskeletal disorders, gastrointestinal conditions, endocrine disorders, chronic renal failure, and neurological disease have a risk of insomnia.

Insomnia is primarily diagnosed by the history of a patient. Some of the assessments and investigations that a doctor may conduct to diagnose insomnia are discussed below:

• Sleep History: Initially the doctor collects the sleep history of a patient for evaluating primary insomnia. It helps the doctor to follow a structured approach to diagnosing insomnia. Sleep history consists of a general description of the disorder such as its duration, severity, variation, and daytime sleep patterns based on the patient experiences and the information given by the patient.
• Medication History: Various medications such as phenytoin and lamotrigine, beta-blockers, antipsychotics, selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors (MAOIs), and non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, diclofenac, naproxen, and sulindac causes insomnia. So, the doctor will check if the patient is taking any of these medications.
• Sleep Diary or Sleep Log: A sleep diary helps to identify maladaptive sleeping habits of a patient such as taking naps or spending excessive time in bed (more than 8 hours). The patient is instructed to write his daily experiences and sleep pattern in the diary. It helps keep track of compliance with behavioral interventions and response to treatment.
• Sleep and Psychological Rating Scale: Epworth Sleepiness Scale (ESS) rates the chance of dozing while a person is doing any of the following activities:
  • Sitting and reading
  • Watching television
  • Sitting inactively in a public place
  • Traveling for an hour without a break
  • While lying down to take rest in the afternoon
  • Sitting and talking to someone for a long time
  • Sitting quietly after lunch without having alcohol
  • While waiting at a traffic signal in a car

Each of the above factors is rated on a 4-point scale as follows:

• 0 – no chances of dozing;
• 1 – slight chances of dozing;
• 2 – moderate chances of dozing; and
• 3 – high chances of dozing.

If an individual scores more than 16, it indicates daytime sleepiness.

• Physical examination and Medical History: A general physical examination will be conducted, and patient’s medical history will be reviewed to know if the individual has conditions such as chronic obstructive pulmonary disease (COPD), asthma, or restless leg syndrome that may disturb sleep.
• Blood Tests: Blood tests are conducted to know if the patient has hormonal disorders such as thyroid diseases, iron deficiency anemia, or vitamin B12 deficiency which causes insomnia.
• Polysomnography:  It is considered the gold standard for measuring sleep in patients with chronic insomnia. Electroencephalogram (EEG), electrooculography (EOG), electromyography (EMG), electrocardiography (ECG), pulse oximetry, and airflow are used to detect a variety of conditions like periodic limb movement disorder, sleep apnea, and narcolepsy. These tests also help to monitor and record the pattern of brain waves, breathing, heartbeat, and eye movements in an individual.
• Actigraphy: It helps to measure the physical activity of an individual. It is a portable device, which a person has to wear on the wrist. Data recorded can be stored for weeks and then downloaded into a computer. Sleep and wake time can be analyzed by analyzing the movement data. Reduced sleep and wake time are recorded in patients with insomnia.

Treatment of insomnia mainly aims at treating the underlying medical condition or psychological problems. Identifying maladaptive behaviors that worsen insomnia helps the patients to develop a healthy lifestyle and eliminate insomnia. The treatment includes a combination of cognitive-behavioral therapies and medications.

Also Read About: Post Traumatic Stress Disorder 

Insomnia Therapies

Cognitive-Behavioral Therapies

• Stimulus Control Therapy: Stimulus control therapy suggests the actions that will trigger sleep. Some of the actions which help to trigger sleep are:
  • Going to bed only when feeling sleepy
  • Use the bedroom only for sleeping
  • Maintain a regular waking time in the morning regardless of the duration of sleep in the previous night
  • Avoid daytime napping
  • Exercise regularly at least 20 minutes in a day 4-5 hours before going to bed
  • Avoid drinking caffeinated beverages such as tea, coffee, soft drinks etc., later than the afternoon
  • Avoid placing high-intensity lights, temperature, noise, etc. in your bedroom

• Sleep Restriction: Sleep restriction therapy consists of restricting the amount of time spent in bed. It helps to prevent excessive daytime sleepiness and promotes early onset of sleep.
• Relaxation Therapies: Relaxation therapies such as progressive muscle relaxation and biofeedback techniques reduce arousal. Attention focusing procedures such as imagery training reduce pre-sleep cognitive arousal. These methods reduce sleep disturbance in patients with stress.
• Cognitive Therapy: Cognitive therapy seeks to alter wrong beliefs and attitudes about sleep in a person.
• Sleep Hygiene Education: Sleep hygiene education helps to develop a healthy lifestyle by practicing good diet and exercise. It teaches methods to reduce environmental factors such as light, noise, temperature, and mattress that may disrupt sleep.
• Behavioral Intervention: It helps the patients to adopt good sleep hygiene and to eliminate behavior incompatible with sleep, such as lying in bed and worrying.

Medications

Medications helps to alleviate insomnia by correcting the hormonal imbalance and treating the underlying psychological disorders.

Some of the medications used for the treatment of insomnia are:

• Benzodiazepines
• Zopiclone
• Zolpidem
• Zaleplon
• Eszopiclone
• Ramelteon
• Tricyclic antidepressants (TCAs)
• Trazodone
• Antihistamines

These medications are usually prescribed for a short period (2 to 3 weeks). Long-term use may cause addiction, impair coordination, balance, or mental alertness.

These medications are contraindicated in patients who are allergic to them, history of drug abuse, or have untreated sleep apnea. They are not safe for pregnant or lactating women.

Insomnia can be prevented by developing better sleeping habits. Some of the good sleeping habits are listed below:

• Sleep only when you feel tired.
• Drink a glass of warm milk before going to bed.
• Make sure your bedroom is quiet and dark.
• Keep your bedroom at a comfortable temperature.
• Do not exercise just a few hours before going to bed.
• Use the bedroom only for sleeping and sexual activity.
• Avoid eating large meals or drinking a lot of water in the evening.
• Avoid taking caffeinated drinks such as coffee and tea, or tobacco late in the day
• Follow regular sleep and wake cycle even on the weekends. It helps the body develop a sleep schedule.
• Avoid reading, watching TV, or worrying in bed as these can cause sleep disturbances
• Avoid taking a nap for more than 30 minutes. Do not take frequent naps and do not nap after 3:00 p.m.
• Take a warm bath before going to bed or read a novel or a story for 10 minutes every night before bed.

Conclusion

If and when suffering from sleeping disorders, it is best to contact a doctor as soon as possible. Because a good night’s sleep is extremely important for a healthy life. So make sure to stay stress-free and enjoy a sound sleep each night, every night.

Can insomnia be life-threatening?

Acute insomnia is not a life-threatening condition. But, secondary insomnia caused due to obstructive sleep apnea can be life-threatening. Remember insomnia itself is not the problem, but the cause of the insomnia is dangerous and can be life-threatening.

What is jet lag?

Jet lag is a temporary imbalance of the body’s normal circadian rhythm, which is caused by high-speed air travel through different time zones. It disrupts the biological clock of the body changes its pre-set orientation towards day and night. Therefore, the person may experience fatigue and sleepiness at odd hours, irritability and various other functional disturbances.

Does sleeplessness go away on its own without taking any treatment?

Yes, transient or acute insomnia caused due to stressful events of life goes away after the stressful phase is over. Persistent or chronic insomnia needs medical treatment.