Patient education: Insomnia (Beyond the Basics)

INTRODUCTION — Insomnia is defined as difficulty falling asleep, difficulty staying asleep, or waking up too early in the morning and not being able to fall back to sleep. People with insomnia sleep less or sleep poorly despite having an adequate chance to sleep. Sleeping poorly or not enough makes it harder to function during the daytime. Insomnia is not defined by the number of hours slept because different people need different amounts of sleep.

One-third to two-thirds of adults report occasional insomnia, and approximately 10 to 15 percent have chronic sleep difficulty. Insomnia is most common in older adults and women.

This article discusses the symptoms, causes, and diagnosis of insomnia. Information about the treatment of insomnia is available separately. (See "Patient education: Insomnia treatments (Beyond the Basics)".)

INSOMNIA SYMPTOMS — Common symptoms of insomnia include:

●Difficulty falling asleep and/or staying asleep

●Variable sleep, such as several nights of poor sleep followed by a night of better sleep

●Daytime fatigue or feelings of sleepiness

●Forgetfulness

●Difficulty concentrating

●Irritability or distress

●Reduced motivation or energy

●Making errors or having accidents more often than usual

●Ongoing worry about sleep

Many people with insomnia also struggle with depression and/or anxiety.

For many people, the symptoms of insomnia interfere with personal relationships, job performance, and daily functioning. People with insomnia may have a small reduction in memory and problem solving compared with people without insomnia. However, they seem to have similar abilities on tests of general cognitive function, perception, verbal ability, attention, and complex thinking.

People with insomnia sometimes have trouble knowing when they are sleeping. For example, you may feel like you have not slept during a period of time, even when objective measurements show that you actually were asleep for some of that time. You may also feel more fatigued than people without insomnia, even if objective measurements show that you are less likely to fall asleep. A person's impaired sense of when they are sleeping may be related to a problem with the body's "sleep-arousal" system, which normally helps you feel awake after sleeping and feel tired before going to bed.

People who are awake at night commonly become concerned that they will perform poorly the next day if they do not sleep enough. Such thoughts can initiate a cycle where being awake at night increases your anxiety, which then makes it more difficult to sleep.

INSOMNIA CAUSES — Insomnia may have many causes. These are divided into factors associated with short-term insomnia and factors typically associated with long-term insomnia.

Short-term insomnia — Short-term insomnia lasts less than three months and is usually associated with stress. Examples of stressful events that can lead to short-term insomnia include:

●Changes in the sleeping environment (temperature, light, noise)

●Loss of a loved one, divorce, or job loss

●Recent illness, surgery, or onset of pain

●Use or withdrawal from stimulants (caffeine), certain medications, illegal drugs (cocaine and methamphetamine), or alcohol

Short-term insomnia often resolves when the stressor is removed or has been addressed. However, sometimes the insomnia continues. This can happen because the things that you do to deal with a bad night of sleep can actually lead to sleep problems the next night. For example, if you take a long nap after sleeping poorly, this will make it harder to fall asleep the next night. The use of alcohol to help fall asleep will cause awakenings and disrupted sleep later in the night. Such behaviors perpetuate insomnia after the initial stressor has resolved.

Short-term insomnia must be distinguished from "circadian rhythm disorders" caused by external factors such as jet lag and shift work (table 1). In these cases, there is a mismatch between the individual's circadian rhythm and the environmental day and nighttime. Time zone changes can make it difficult to fall asleep at the desired clock time, since this no longer aligns with the person's internal circadian rhythm. Similarly, rotating shift work or working at night can cause difficulty sleeping due to ongoing misalignment of the internal circadian rhythm and the time available to sleep.

Long-term insomnia — Long-term (or chronic) insomnia lasts longer than three months and occurs at least three nights per week. Chronic insomnia is associated with an increased risk of developing significant medical problems; if you have had problems with insomnia for more than three months, you should talk with your health care provider. Even though chronic insomnia is a separate problem, it often occurs along with other conditions, including:

●Mental health problems, such as depression, anxiety disorders (including panic attacks), and posttraumatic stress disorder (PTSD), problems with alcohol or drugs, or some medications that are used to treat mental health problems

●Medical illnesses such as respiratory disorders, high blood pressure, diabetes, and disorders that cause pain, stress, or limitation of movement, or some medications that are used to treat these problems

●Neurological disorders, such as Parkinson disease and Alzheimer disease

●Other sleep disorders, such as sleep apnea, restless legs syndrome, periodic limb movements, and circadian rhythm disorders (see "Patient education: Sleep apnea in adults (Beyond the Basics)")

Chronic insomnia can also occur independently. In some cases, it can be passed along in families. Chronic insomnia can exist in infants, children, and adolescents as well as in adults. Assessment of insomnia in children should also include information from the caregiver as children cannot always report accurately about their sleep habits, routines, and quality. Chronic insomnia must be distinguished from "delayed sleep wake phase disorder" (DSWPD) and "advanced sleep wake phase disorder" (ASWPD). In DSWPD, individuals have difficulty falling asleep when they try to go to sleep earlier than their internal circadian rhythm allows. DSWPD is common in teenagers and young adults, and half of adolescents with DSWPD also have insomnia symptoms. ASWPD can include awakening early in the morning and being unable to fall back asleep. This is more common in older adults and is often accompanied by complaints of sleepiness in the evening hours.

Short duration sleep and sleep deprivation — Insomnia is frequently confused with a short sleep requirement or sleep deprivation, but these are not the same.

●Short sleep requirement – Some people require less sleep than others and can function without difficulty after sleeping fewer hours. People who sleep less but have no daytime sleepiness or other daytime symptoms are sometimes called "short sleepers" and do not have insomnia disorder based only on their short sleep time. Needing less sleep does not necessarily mean that you have insomnia unless you also have daytime symptoms, such as sleepiness or difficulty functioning.

●Sleep deprivation – Similar to people with insomnia disorder, people who do not spend enough time in bed to get the sleep they need have difficulty functioning during the daytime. The difference is that people with insomnia disorder are unable to sleep normally even when they have the time and opportunity to sleep, while someone who is sleep deprived will fall asleep quickly and sleep normally if given the opportunity. Chronic loss of sleep, caused by spending fewer than the necessary number of hours in bed to get the sleep you need, is probably the most common cause of daytime sleepiness.

INSOMNIA DIAGNOSIS — If you seek help for insomnia, your health care provider will start by asking about problems you have with your sleep and how much time you spend in bed. If you share your bed or room with another person, they may be able to help to answer these questions. Your provider will also ask you about symptoms of other sleep disorders or medical and mental health problems that might make it hard to sleep well.

You may be asked to keep a daily sleep diary, which is a record of sleep times (including time spent in bed and time spent actually sleeping) for one to two weeks.

Your provider may ask other questions to figure out the cause of your insomnia. A physical examination can help determine if there are medical or neurologic conditions causing or worsening your sleep problems.

While tests to measure your sleep are not required to diagnose insomnia, in some cases, your provider might recommend tests to help identify other sleep disorders. These tests may include polysomnography, actigraphy, or a home sleep apnea testing if your provider thinks you might have sleep apnea:

●Polysomnography – Polysomnography is a formal sleep study done in a sleep laboratory. It is a painless test that uses sensors that are attached to your body to record movement, brain activity, breathing, and other physiologic functions. This test may be used when another sleep disorder is suspected or if your insomnia has not responded to treatment.

●Actigraphy – Actigraphy records activity and movement with a monitor or motion detector, using a watch-like device worn on the wrist throughout the day and night. The recording is conducted over one to two weeks at home to gather estimates about how much and at what times you are sleeping. These are similar to the devices people wear to monitor their own sleep but have met higher standards for accuracy than devices sold to consumers.

●Home sleep apnea testing – Home sleep apnea testing is commonly available and allows patients to sleep at home with a portable recording device. Sensors are attached to the face and a finger, and a belt is placed around the chest to determine whether changes in breathing and oxygen levels during the night are related to the patient's poor sleep. These tests are only used for evaluation of sleep apnea in appropriate patients.

INSOMNIA TREATMENT — If your insomnia is related to another problem such as abnormal breathing during sleep, that problem should be treated at the same time your insomnia is being treated.

The treatment of insomnia is discussed in detail separately. (See "Patient education: Insomnia treatments (Beyond the Basics)".)

RESOURCES — To find a provider who specializes in sleep, online resources are available:

●The Society for Behavioral Sleep Medicine (SBSM) lists providers who are members of the organization by geographic region within and outside of the United States and provides accreditation to training programs. Individuals who are Diplomates of the American Board of Behavioral Sleep Medicine are also listed on the SBSM website.

●Accredited sleep disorders centers through the American Academy of Sleep Medicine (AASM) are required to provide comprehensive care for insomnia disorder, either within the center or through referrals. Accredited centers can be searched by United States zip code on the AASM website.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Insomnia (The Basics)
Patient education: Nocturnal (nighttime) leg cramps (The Basics)
Patient education: Restless legs syndrome (The Basics)
Patient education: Daytime sleepiness (The Basics)
Patient education: Jet lag (The Basics)
Patient education: What is a sleep study? (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Insomnia treatments (Beyond the Basics)
Patient education: Sleep apnea in adults (Beyond the Basics)
Patient education: Sleep insufficiency (The Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Classification of sleep disorders
Risk factors, comorbidities, and consequences of insomnia in adults
Evaluation and diagnosis of insomnia in adults
Overview of the treatment of insomnia in adults
Cognitive behavioral therapy for insomnia in adults
Pharmacotherapy for insomnia in adults

The following organizations also provide reliable health information.

●National Library of Medicine

     (medlineplus.gov/sleepdisorders.html)

●American Academy of Sleep Medicine

     (https://aasm.org/)

●National Heart, Lung, and Blood Institute

     (www.nhlbi.nih.gov/health/resources/sleep)