Insomnia is a miserable but misunderstood condition.
In this guide we’ll start from the very beginning and walk through everything you need to know about insomnia, from the basic building blocks all the way up to advanced techniques for treatment.
Let’s dive in!
- What is Insomnia?
- What Causes Insomnia?
- What are the Symptoms of Insomnia?
- What are the Long-Term Effects of Insomnia?
- What are the Treatments for Insomnia?
What is Insomnia?
In it’s simplest form, insomnia can be defined as significant difficulty falling or staying asleep. People with insomnia desperately want to sleep better but feel as if they can’t. They often describe being awake for long stretches at night, taking a long time to fall asleep initially, feeling as if they haven’t slept at all, and anxiety or worry about sleep and it’s consequences.
Importantly, insomnia does not necessarily mean sleep deprived. In fact, most people with insomnia get sufficient sleep on a regular basis and on average only get 25 minutes less sleep than healthy sleepers without insomnia. Where people with insomnia do differ from the rest of the population is in terms of sleep efficiency and sleep anxiety.
People with insomnia almost always have poor sleep efficiency, meaning they spend too much time in bed relative to the amount of actual sleep they get. They also tend to think about and worry about their sleep and the potential negative consequences of not getting enough of it. More on both sleep efficiency and sleep anxiety later.
According to the most recent research, Insomnia is thought to occur in 10-20% of the population, is more common in women and older adults, and about half of the total number of cases are considered chronic. On average, sleep maintenance issues (trouble staying asleep) tend to be the most common type of insomnia symptom, and on average people with insomnia tend to underestimate the amount of sleep they get by up to an hour and a half.
It’s also important to understand that insomnia itself is a general term for difficulty sleeping, and while both professionals and lay people alike use the term casually with this general meaning, there is a technical definition and diagnostic criteria for insomnia.
Technical Definition of Insomnia and Diagnosis
According to the DSM-5, a diagnosis of primary insomnia requires that a person have difficulty with one or more of the following:
- Difficulty falling asleep (initial insomnia)
- Difficulty staying asleep (middle insomnia)
- Waking up too early (terminal insomnia)
Additionally, the insomnia must:
- Cause significant distress or impairment in daily life
- Occur at least 3 nights per week
- Be present for at least 3 months
- Occur despite adequate opportunity for sleep
- Not be better explained by another condition (e.g. Sleep Apnea, Depression, Hyperthyroidism, substance abuse or addiction).
With the official diagnostic criteria in mind, there are several important sub-types or classification of insomnia that are worth reviewing briefly.
Primary Insomnia vs Secondary Insomnia
Primary Insomnia is the term for insomnia that is unrelated to any other physical or mental health disorder. Primary insomnia is also sometimes called idiopathic insomnia (of unknown origin) or nonorganic insomnia (not caused by an organic physiological cause).
Secondary Insomnia, on the other hand, is when the insomnia is known to be caused by or directly related to another condition.
For example, someone who started abusing cocaine on a regular basis might well develop a difficulty falling and staying asleep. But because it was presumably caused by and maintained by the cocaine addiction, the insomnia would be thought of as secondary to the substance abuse problem.
Similarly, other medical or mental health conditions such as hyperthyroidism, chronic pain, Parkinson’s Disease, anxiety, bipolar disorder, and depression can also cause and sustain insomnia. In situations like these when the insomnia is secondary, it’s often best thought of as a symptom or set of symptoms of another condition.
Lastly, insomnia is sometimes described as being co-morbid with another condition such as depression or diabetes. When two conditions are co-morbid, it simply means that they occur together, but there isn’t necessarily a direct causal connection between the two.
Paradoxical Insomnia is the term for a type of insomnia characterized by a high tendency to misperceiving sleep states as wakefulness. In other words, a person with paradoxical insomnia regularly describes getting little to no sleep at night; but when they are subjected to objective clinical recording of their sleep, they demonstrate largely normal sleep patterns in terms of both quality and quantity of sleep. Paradoxical Insomnia is also sometimes referred to as sleep state misperception, pseudoinsomnia, or sleep hypochondriasis.
Chronic vs Acute Insomnia
Sometimes a person’s insomnia is described as chronic, which means that it has been ongoing for some time, typically months or years at a relatively consistent intensity. If you’ve consistently had trouble falling asleep at night and going back to sleep when you wake up, and this has been the case for years, that might be termed chronic insomnia.
Alternatively, insomnia can be termed acute meaning that it was or has been of limited duration. If you recently went through a divorce and subsequently had a period of several weeks when you had trouble with your sleep, that could be termed acute insomnia.
Finally, transient insomnia is sometimes used to refer to very brief episodes of difficulty sleeping, usually on the scale of days to a week. For example, many people experience transitory insomnia when adjusting to a new medication, sleeping in a new environment, or after traveling. Some healthcare providers will also use the term intermittent insomnia to describe a course of insomnia that waxes and wanes in intensity or even appearance—in other words, it comes and goes.
What Insomnia is Not (i.e. Other Sleep Disorders)
It’s helpful to be clear about other sleep disorders that are related to but distinct from insomnia. Below are brief descriptions of the most common non-insomnia sleep disorders:
- Obstructive Sleep Apnea. The most common form of breathing-related sleep disturbance, obstructive sleep apnea is a condition where a person’s airway is partially obstructed or blocked while they sleep leading to shallow or even paused breathing while sleeping. Consequently their oxygen levels are low throughout the night resulting in poor sleep quality and excessive daytime sleepiness. Old age and increased tissue around the airways due to obesity or decreased muscle tone are thought to be the most common causes. A diagnosis of obstructive sleep apnea can only be made following a formal sleep study, and the treatment typically involves use of a CPAP machine during sleep.
- Central Sleep Apnea. Similar to obstructive sleep apnea, central sleep apnea involves a loss of proper oxygen intake during sleep, but it results from neurological dysfunction related to the mechanisms in the brain responsible for regulating respiration. Again, a sleep study is required for diagnosis and use of a CPAP machine is the most common treatment.
- Narcolepsy. Narcolepsy is a neurological condition marked by excessive daytime sleepiness and a propensity to suddenly fall asleep during the day. It can also co-occur with cataplexy, which is a sudden loss of muscle tone. The causes of narcolepsy are unknown, and there is no known cure, although it can be managed with medication and lifestyle changes.
- Restless Leg Syndrome. Restless Leg Syndrome is a disorder that leads to a variety of uncomfortable sensations in the legs including an urge to move, restlessness, buzzing sensations, and even limb jerking. It typically, but not always, occurs during sleep or deep relaxation, and as a result, can cause significant sleep impairment. The causes are not well-understood, although kidney failure, antidepressant use, neuropathy, and pregnancy are all thought to be risk factors.
- Periodic Limb Movement Disorder. Not to be confused with restless leg syndrome, periodic limb movement disorder involves involuntary limb movement during sleep which often result in poor sleep quality and daytime sleepiness. A sleep study is typically required for diagnosis. Risk factors for the disorder include being a shift worker, stress, and use of hypnotic medication. While there is no known cure, the condition is typically treated with anti-Parkinson’s medication, as well as narcotics, benzodiazepines, and anticonvulsants.
- Circadian Rhythm Disorders.
- In Delayed Sleep Phases Disorder a person’s Circadian signaling is significantly delayed and often longer than 24 hours. As a result, people with this condition typically do not naturally become sleepy until 2:00am or 3:00am and can sleep until midday. There is no known cure and attempting to function on a more typical schedule is almost never successful. Consequently, lifestyle changes are typically recommended (I.e. finding a job or school situation that can accommodate a late schedule).
- Advanced Sleep Phase Disorder is essentially the opposite of delayed sleep phase disorder and results in people becoming sleepy very early in the evening (6:00pm to 8:00pm) and waking up in the early morning hours. Unlike most sleep disorders, people with this condition do not typically complain of excessive daytime sleepiness.
- Non-24-hour Sleep-Wake Disorder occurs predominantly in people with total blindness and is characterized by a longer than 24 hour sleep-wake cycle, meaning that in order to function optimally their sleep and wake times must continually change, often leading to difficulties with their jobs or social/interpersonal lives.
- Parasomnias. The term parasomnia refers to a class of sleep disorders that involve unusual behaviors, perceptions or emotions during sleep and typically result from abnormal variations in wakefulness during or around sleep.
- Sleepwalking: Present in approximately 4% of adults, sleepwalking is often associated with high levels of stress or anxiety as well as certain medications or substances like alcohol.
- Sleep Terrors: While most dreams and nightmares occur during REM sleep, sleep terrors occur during deep sleep and involve waking up suddenly in a near-panic attack like state, often inconsolably so.
- Teeth Grinding (Bruxism): Typically the result of stress or anxiety, problematic teeth grinding can lead to headaches, migraines, and other complications in addition to dental problems.
- Sleep Sex (Sexsomnia): When a person engages in sexual acts while asleep, typically without any recollection upon waking.
- Sleep Related Eating Disorder: Eating and bingeing at night while asleep without conscious recollection upon waking.
- Exploding Head Syndrome: When a person experiences a sudden imagined and severe noise (e.g. bomb exploding, gunshot, balloon pop) while falling asleep or waking up.
- REM Sleep Behavior Disorder: Because of an abscense of muscle Antonia during REM sleep (often a side effect of antidepressants), a person with REM Sleep Behavior Disorder is able to act out their dreams, which may result in injury to themselves or a others.
- Sleep Paralysis: When a person is aware but unable to move while waking up or falling asleep. Typically lasts less than a few minutes and is generally accompanied by intense fear or anxiety.
What Causes Insomnia?
Insomnia is a complicated and in some ways poorly-defined condition, as evidenced from the discussion above. Similarly, the causes of insomnia are not nearly as well-defined and consistent as you might hope for. In this section we’ll take a look at the many factors that play a role in the development and maintenance of insomnia.
Direct Causes of Insomnia vs Predisposing Factors
When we talk about the causes of insomnia, it’s helpful to make a distinction between Direct Causes and Predisposing Factors.
Direct causes of insomnia are things that have a known direct effect on insomnia and poor sleep. Worrying about sleep and the anxiety that results directly suppresses the body’s need for sleep (Sleep Drive) and is therefore a direct cause of insomnia.
On the other hand, having an older age appears to predispose a person to developing insomnia, without knowing the reasons why that might be. It simply means that, statistically, a 70-year-old is more likely to have insomnia than a 20-year-old.
Finally, certain things could be both a direct cause and a predisposing factor. Female gender, for instance, predisposes a person to an increased risk for developing insomnia, although the actual relationship between gender and insomnia is unclear. It could be that hormonal changes associated with ovulation, menstruation, and/or menopause could all have direct physiological effects on sleep. On the other hand, women are, for example, more likely to be diagnosed with an anxiety disorder or need to breastfeed a child in the middle of the night, both of which affect sleep.
Initial Cause of Insomnia vs Sustaining Factors
Furthermore, what causes someone’s insomnia initially may not be the factor that most significantly sustains it in the present, and therefore may not be the best target of treatment. In other words, there’s an important distinction between an Initial Cause for insomnia and a Maintaining Factor of insomnia.
For instance, traveling and associated jet lag may initially cause insomnia, but over time bad sleep habits and anxiety about poor sleep may actually be the things that are most strongly contributing to the insomnia and therefore should be the primary focus of treatment.
Factors that may cause insomnia
With those distinctions in mind, below is a list of many of the most commonly known factors that can lead to insomnia or exacerbate insomnia. Note that many of the following causes of insomnia are also symptoms of insomnia.
- Stress. The body’s stress response is a useful tool for dealing with dangerous or challenging situations. By releasing adrenaline and activating the fight or flight response, we are capable of doing more than we normally would—running faster, lifting more weight, paying attention better, etc. And while most activities benefit from at least a little adrenaline (and stress), falling asleep isn’t one of them because the sleep system is in direct opposition to the arousal system—the more relaxed you are the less stressed you are, and the more stressed you are the less relaxed you are. And because relaxation is the doorway to sleep, being stressed and having a hard time relaxing makes it difficult to sleep well.
- Poor sleep habits. There are too many poor sleep habits to list here, but one example is sleeping in on the weekends. Even though it feels great to sleep in an extra hour on Saturday and Sunday morning, the mild benefit of getting a little more (light) sleep on the weekends is vastly outweigh by the negative effects of an inconsistent sleep schedule. In fact, people who consistently go to bed later and wake up later on the weekends, suffer from social jet lag which is comparable in its effects to regular jet lag.
- Sleep Effort. The more we try to sleep the more alert and aroused we become, which leads to suppression of our sleep drive and difficulty falling asleep. It’s counterintuitive, but sleep is not something we need to do; it’s something that will happen to us as long as we get out of the way.
- Sleep Anxiety. When we worry about our sleep or the consequences of poor sleep, we become anxious. And anxiety is, by definition, a state of increased arousal. Consequently, when we’re anxious we become less sleepy, have a harder time falling or staying asleep, and create a self-fulfilling prophecy of not sleeping well.
- Lack of exercise or physical activity. One of the best ways to generate more sleep drive and therefore fall asleep faster and sleep more soundly is to exercise regularly (or at least maintain an active lifestyle). Conversely, when we aren’t active enough during the day, our need for deep, restorative sleep is lower and as a result we don’t sleep as well.
- Shift work and irregular schedules. As described in the poor sleep habits section, when working a shift job we essentially confuse our normal circadian rhythms which operate primarily by sunlight exposure. While there are some steps you can take to minimize the effects, a substantial body of research shows that shift work is simply hard on the body and often leads to sleep difficulties like insomnia.
- Medical and Mental Health Conditions. Many medical and mental health conditions negatively impact our sleep and can cause or contribute to insomnia. Some of the most common include:
- Gostrointestinal problems like IBS or acid reflux
- Thyroid issues (e.g. hyperthyroidism)
- Neurological conditions like M.S. or Parkinsons
- Chronic pain
- Non-Insomnia sleep disorder such as central or obstructive sleep apnea, restless leg syndrome, circadian rhythm disorders, etc.
- Bipolar Disorder
- Medications. In addition to the many diseases and disorders that can cause insomnia, many medications can interfere with sleep, including:
- Allergy medications
- Cold medications
- Blood pressure medications
- Thyroid medications
- Hormonal birth control
- Asthma medications
- ADHD medications
- Statins and cholesterol medications
- Beta blockers
- ACE inhibitors
- Diet. What and when we eat can have an impact on our sleep. In general, it’s best to avoid eating within a couple hours of bedtime and to avoid heavy meals and spicy foods before bed as they can lead to indigestion.
- Legal Drugs. Many legal drugs such as caffeine, nicotine, and alcohol are known to negatively impact sleep. Caffeine and nicotine, for instance, both have stimulating effects and can inhibit the body’s natural drive for sleep. Alcohol, on the other hand, is a depressant and can exert negative effects on sleep by making breathing-related sleep disorders like apnea worse and because the process of metabolizing alcohol can sleep to sleep disturbances directly.
- Gender. Although the reasons are not well-understood, women suffer disproportionately from insomnia compared to men. One possible mechanism is fluctuations in hormone levels due to menstruation or menopause.
- Age. Older folks tend not to sleep as well as younger ones, although it’s a myth that our need for sleep declines with age. Possible explanations for poorer sleep with age include increased physical problems and pain, increased need for urination, and less time spent in deeper stages of sleep.
- Blue Light. Exposure to blue light in the evening does appear to have some small negative effects on sleep, although the research is mixed.
- Napping. Similar to eating, when done in excess and close to bedtime napping can significantly impair our sleep by way of a reduction in sleep drive. That being said, brief (20-30 minute) naps in the early afternoon shouldn’t be a problem for most folks.
- Temperature. While unlikely to cause insomnia itself, having an overly cold or overly warm sleeping environment can negatively effect sleep. The ideal temperature for sleep appears to be between 68 and 70 degrees Farenheight.
- Mattress Quality. Sleeping on an uncomfortable mattress can affect sleep quality, especially your ability to fall asleep. Given that we spend upwards of 8 hours a day on them, investing in a quality mattress is likely worthwhile.
- Light and Sound. Too much ambient light and noise in your bedroom or sleep environment can contribute to sleep difficulties. While these effects are typically mild compared to larger factors like Sleep Anxiety and Sleep Drive, minimizing the amount of excess light and sound can be useful. Many people also find white noise machines to be helpful, especially if they suffer from tinnitus.
- Pets. Pets in the bedroom should be avoided at all cost if sleep difficulties are present. This is one of the most commonly overlooked factors in poor sleep.
- Noisy, chaotic, or violent neighborhood. While it can be difficult to address, a person’s greater sleep environment can have a significant impact on the quality of their sleep.
- High altitudes. Some research has shown that sleeping in extremely high altitudes can have a negative impact on sleep.
- Pregnancy. For obvious reasons being pregnant can make sleep difficult, especially in the third trimester.
- Illicit Drug Use. The use of illicit drugs such as cocaine, amphetamines, opiates, and many other classes of substance have been shown to negatively impact sleep in a variety of ways. Notably, while some drugs such as marijuana have shown some limited efficacy in terms of helping people fall asleep initially, long-term use almost universally leads to poor sleep quality as well as insomnia directly related to withdrawal effects.
- Children/infants/sleep training. Having children in the home or bedroom can obviously have a negative effects on sleep, especially infant who are not capable of sleeping through the night. The latest research suggests that by 4 months most babies are capable of sleeping through the night if properly sleep trained.
- Noisy (snoring) or active partner in bed. Having a noisy or physically active partner in bed can cause significant sleep disturbances. In many cases, sleeping in separate beds or rooms while an underlying cause or condition resolves is the preferred strategy.
What are the Symptoms of Insomnia?
Insomnia Symptom #1: Trouble falling sleep at night
Difficulty falling asleep at night—sometimes called initial insomnia or sleep latency—is one of the most common symptoms of insomnia. A common experience of those with insomnia is feeling like their mind “won’t shut off” or is “running a million miles an hour” while in bed waiting to fall asleep. More often than not, it results from 3 factors: a short or non-existent sleep runway, sleep effort (especially, sleep anxiety), or insufficient sleep drive.
- Sleep Runway. A sleep runway is a period of time before getting into bed that is relaxing and sleep promoting. It often involves reading, watching tv, stretching or meditating, or some other similarly non-arousing activity. Having a sleep runway routine is important because it gives your mind time to unwind from a long, active day and go into relaxation mode which is essential in order to fall asleep. Nobody goes from alert or aroused to sleepy; sleep only arrives through the doorway of relaxation.
- Sleep Effort. Sleep effort—any mental or physical act of trying to sleep—signals to your brain that it should go into a more aroused state and in the process inhibits your ability to sleep. Whether it’s counting sheep, preparing your favorite sleepy time tea, or doing deep breathing exercises, if it’s done with the intention of falling asleep, it will paradoxically wake you up and make it harder to fall asleep. Many people lay in bed unable to fall asleep because mentally they are trying to fall asleep, which is actually making it more difficult.
- Insufficient Sleep Drive. Sleep drive is the body’s need for deep, restorative sleep. It builds up over the course of the day and eventually crosses a threshold, at which point we become sleepy and then are able to fall asleep. However, when people get into bed before they are truly sleepy (which is very different than being “tired” or “exhausted”) they will remain awake and probably end up worrying about not falling asleep—which, consequently, not only wakes you up, but also conditions your brain to associate your bed with worry rather than sleep, making it that much harder to fall asleep the next time around.
Insomnia Symptom #2: Waking up during the middle of the night and having a hard time going back to sleep
It’s normal to wake up in the middle of the night. In fact, everyone wakes up at least several times throughout the night as a part of the normal sleep cycle even if they don’t remember it. People with insomnia may wake up many times throughout the night, but by far the biggest struggle is not being able to fall back to sleep after waking up, sometimes called middle insomnia.
Middle insomnia is usually the result of insufficient sleep drive and sleep anxiety. As we discussed earlier, sleep drive is your body’s need for deep sleep (technically stage 3 sleep). When we’re in deep sleep, we sleep very soundly and it’s actually difficult to be woken up. If you find yourself waking up frequently throughout the night, it may be because you’re not getting enough deep sleep. The solution often involves the use of a temporary course of sleep restriction to build up more sleep drive.
However the biggest culprit in middle insomnia is usually sleep anxiety. In other words, people wake up in the middle of the night and then start to worry about being up, not being able to fall back to sleep, or the consequences of not sleeping well. As a result, they begin to feel more aroused and anxious which makes it harder to fall back asleep. The most effective solution for sleep anxiety in the middle of the night is a collection of techniques called stimulus control that involve getting out of bed and doing something relaxing until you feel sleepy gain.
Insomnia Symptom #3: Waking up too early
Sometimes insomnia is characterized primarily by waking up too early, or what’s technically called terminal insomnia. Terminal insomnia can often be an indicator of poor sleep efficiency, meaning you’re spending too much time in bed and not enough time actually sleeping. However, terminal insomnia may also be a symptom of depression, so it’s worthwhile to assess for that possibility as well. Finally, some sleep medication, while helpful in getting you to fall asleep, may actually put an artificial ceiling on the duration of your sleep since processing the meds often interferes with your sleep cycles and could lead to waking up too soon.
Other Symptoms of Insomnia
- Irritability or moodiness. It’s common with chronic insomnia to experience increased mood volatility and irritability. Many people describe feeling more “on edge” and being “always on the verge of getting upset.”
- Difficulties with attention or memory. Mild to moderate deficits in attention and memory are not uncommon with insomnia. You may find yourself getting more easily distracted, having a hard time focusing, or struggling to recall previously known words or pieces of information. It’s important to note, however, that most people with insomnia are not severely sleep deprived, meaning any deficits in memory or attention are typically not seriously impairing.
- Daytime sleepiness and/or feeling not well-rested after sleep. One of the most common symptoms of anxiety is feeling not rested or sleepy throughout the day. If you find yourself dozing off easily, having a hard time staying awake in meetings or other slow activities, it could be a sign of insomnia and insufficient sleep. Note, however, that it’s normal to feel somewhat sleepy for the first hour or so after getting out of bed in the morning (grogginess) as well as in the mid afternoon. Also, diet, lack of exercise or physical activity, boredom, and a host of other factors could also play a role in feeling unrested during the day, so it’s important to rule those out before blaming insomnia.
- Higher than usual rate of accidents or mistakes or clumsiness. If insomnia is leading to significant sleep deprivation, a person may experience higher than expected rates of errors, mistakes, or even serious accidents.
- Sleep anxiety. A classic example of a symptom that is also a cause of insomnia, people often begin to worry about sleep and the effects of not sleeping well as a result of poor sleep. If you find yourself worrying throughout the day about sleep, taking excessive precautions to ensure good sleep, or worrying about not falling asleep while in bed, sleep anxiety is likely a factor in your insomnia.
- Headaches. Some people report higher than normal rates of headaches as a result of insomnia.
For more formal assessment tools for insomnia, the following is a brief selection of tools to better understand the extent to which someone may or may not have insomnia:
- The Insomnia Severity Index. While not diagnostic, this brief self-assessment tool can help you gauge the severity of your insomnia.
- The Epworth Sleepiness Scale. Helps you get a sense for the severity of your daytime sleepiness which is often a marker for insomnia.
- Sleep Efficiency Calculator. Sleep Efficiency—the ratio of hours slept to hours in bed—is often used as a rough marker for insomnia severity. 80% to 90% is usually considered optimal.
- Sleep Diary from the National Sleep Foundation. A sleep diary is often the first thing a sleep specialist will have you fill out in order to get a more quantitative sense for what your sleep patterns really look like.
What are Long-term Effects of Insomnia?
First it’s important to remember the distinction between insomnia and sleep loss. Insomnia doesn’t not necessarily imply sleep loss, but rather, difficulty with sleep. As a result, what most people really want to know about is the long-term effects of sleep loss.1
While there’s been a lot of media coverage about how crucial it is to get at least eight hours of sleep per night and how dire the consequences can be if you don’t, a closer look at the research suggests much of this hand wringing about sleep is actually far overstated, primarily for two reasons:
Most of the research on the long-term effects of insomnia doesn’t do a very good job of disentangling the effects of insomnia specifically from other related conditions and issues such a stress, medical conditions, depression and anxiety, medication use, etc. The ones that do tend to show mild to non-existent effects. In other words, once you account for other lifestyle and medical factors, the chances of increased mortality or serious health consequences—even people with less than ideal sleep durations—is mild to none.
In general, 7 hours seems to be the amount of sleep associated with the least risk for long-term negative effects, although anywhere between 6 and 8 hours is considered normal my most sleep experts and contributes most to the many benefits of quality sleep.
In other words, as long as you’re not consistently getting less than 5.5 or 6 hours of sleep, you probably don’t have much to worry about in terms of long-term health consequences. In fact, the anxiety associated with worrying about the negative effects of poor sleep is probably doing more harm that your actual sleep.
All that being said, there important negative consequences to consistent very short sleep, including:
- Poor performance at work or in school. While most people function well on 6 to 8 hours of sleep per night, if you’re consistently getting less than that it could be hampering your performance or productivity during the day. Attention, focus, memory, and creativity could all suffer if you are chronically sleep-deprived.
- Exacerbation of medical conditions like heart disease or diabetes. Consistently poor sleep can also have negative consequences for other health conditions, including lowered immune system functioning. However, most of these studies only showed an effect in very sleep deprived individuals who were getting, for example, 4 hours of sleep per night (remember, most people with insomnia consistently underrate how much sleep they’re actually getting).
- Mental health disorders like anxiety and depression. Similar to physical conditions, sleep deprivation can negatively affect a mental health condition such as anxiety, depression, eating disorders, bipolar disorder, substance abuse, etc. What’s more, if you’re in therapy or actively working to improve a mental health struggle, chronic sleep deprivation can reduce your ability to focus and maintain energy to do the work necessary.
- Increased risk for motor vehicle and other accidents. Perhaps the most severe consequence of major sleep loss or sleep deprivation is an increased risk for accidents while operating heavy machinery or driving. We know that people with significant day time sleepiness, are at significantly increased risk for major accidents or errors.
What are the Treatments for Insomnia?
Traditionally there have been two types of treatments for insomnia, psychological and pharmacological. Psychological treatments focus on modifying behavioral and mental habits that may be interfering with sleep, while pharmacological treatments use a variety of drugs to help people with insomnia fall and stay asleep.
Most professional organizations and guidelines, including the American College of Physicians, recommend psychological treatments as first-line since they have generally been shown to be more effective and have fewer adverse effects compared to pharmacological treatments.
Psychological Treatments for Insomnia
Over the years there have been many psychological and behavioral approaches to insomnia that have been studied and implemented successfully for people suffering from insomnia. In the last 10 to 20 years, most of these techniques have been gathered under an umbrella treatment methodology called Cognitive Behavioral Therapy for Insomnia, and incorporated into one unified treatment.
Cognitive Behavioral Therapy for Insomnia (or CBT-I, for short) typically makes use of the following techniques and interventions:
- Stimulus Control. Stimulus control is a set of techniques aimed at filtering out sleep-disturbing phenomena from the sleep environment so that the body’s natural sleep response can engage and operate successfully. One common stimulus control technique is called scheduled worry and involves setting aside a fixed amount of time before bedtime to deliberately worry about anything that’s bothering you or on your mind. By creating a habit of worrying at a specific time with fixed limits and boundaries, it has been shown to reduce the amount of anxious and intrusive thoughts that people experience in bed while trying to fall asleep.
- Sleep Restriction. Sleep restriction is a well-studied and highly effective technique for improving the quality of one’s sleep. By temporarily restricting the number of hours a person spends in bed from, say 8 to 6, you increase the person’s need for sleep (technically, their sleep drive) and therefore increase the odds that the quality of their sleep is higher. Once the person has adjusted to this higher quality of sleep for a week or two, time is gradually added back onto their sleep schedule until they are able to achieve both a high quality of sleep and a sufficient quantity of sleep.
- Formal Relaxation Techniques. Many people’s insomnia is exacerbated by a difficult time relaxing and winding down after a stressful days. As a result, it is often very beneficial to build in structured relaxation practices to their days and their evening routines. Progressive Muscle Relaxation, Diaphragmatic Breathing, Yoga, and Mindfulness Meditation are all examples of relaxation techniques that have been shown to be effective.
- Cognitive Restructuring. Cognitive restructuring and is a technique borrowed from traditional cognitive behavioral therapy that teaches people how to identify, challenge, and modify unrealistically negative thoughts or self-talk about sleep or it’s consequences. Many people with insomnia, for instance, have the mental habit of catastrophizing sleep difficulties. In other words, they tend to habitually assume the worst about the consequences of poor sleep. As a result, they end up experiencing increasing amounts of worry and anxiety about their sleep, which in turn makes it less likely that they will fall asleep. Cognitive restructuring is about learning to replace those unhelpful mental habits around sleep with more accurate ones and eliminate a significant amount of sleep anxiety.
Cognitive Behavioral Therapy for Insomnia is almost universally regarded as the best choice for the treatment of insomnia because it is the most effective, the beneficial effects persist even after treatment has concluded, and there are no known side effects.
Pharmacological Treatments for Insomnia
While there is a long history of prescribing medications as sleep aids, there are typically considered a second-line treatment because they lack demonstrated superior effects to other treatments, their effectiveness only persists as long as the medication is actively taken, and there are often serious short-term side effects and the long-term side effects are unknown. Most recommendations for the use of drugs to treat insomnia explicitly suggest limited and short-term use.
In general there are three categories of drugs for the treatment of insomnia, hypnotics, benzodiazepines, and antidepressants.
- Hypnotics. Hypnotics are a class of drug whose primary function is to induce sleep. The most common hypnotics include Ambien (zolpidem), Lunesta (eszopiclone), Sonata (zaleplon). The research on the effectiveness and safety of these drugs is mixed. While most have been shown to modestly improve sleep latency, there’s evidence that they can actually impair the quality of sleep or limit its duration. They can also have detrimental side effects including anxiety, depression, increased risk for accident or injury (especially while driving), sleep walking, “sleep driving,” gastrointestinal issues, headache, sleep paralysis, memory impairments, and more.
- Benzodiazepines. Benzodiazepines are a class of drug typically prescribed as a sedative or anxiolytic. The most commonly prescribed benzodiazepines include, Xanax (alprazolam), Klonopin (clonazepam), and Librium (chlordiazepoxide). They are often prescribed as a sleep aid, however, since they’re fast acting and can help people with insomnia fall asleep more quickly, in part because of their anti-anxiety effects. However they also come with significant downsides. They are generally not recommended for anything but short-term use (and even then only intermittently) due to their high risk for addiction and dependence. Furthermore, while they can help with sleep onset issues, like alcohol, they tend to disrupt overall sleep architecture, in particular, deeper more restorative stages of sleep. Finally, there are many reported negative side effects, including daytime drowsiness, lightheadedness, headaches, rebound insomnia, and increased risk for falls and injury in older adults.
- Antidepressants. Antidepressants are often prescribed off-label for sleep issues since they are thought to have sleep-promotingng qualities. Trazadone is one of the the most commonly prescribed antidepressants for sleep. The evidence for the effectiveness of antidepressants for sleep is generally poor; additionally, there may be significant side effects including dry-mouth, constipation, sexual dysfunction, plus sleep fragmentation and REM sleep suppression. Additionally, contrary to popular wisdom, antidepressants can often lead to dependence and not insignificant withdrawal effects (including insomnia) when people try to discontinue them.
- Other Pharmacological Substances. In addition to the three primary classes of drugs prescribed for sleep listed above, there are several other types of drugs or substances that are sometimes used for sleep: Melatonin is a hormone that when taken exogenously may have some utility in helping people with circadian rhythm sleep disturbances improve their sleepy, although it hasn’t been shown to have significant positive effects on insomnia. Benadryl is technically an antihistamine but due to its side effect of producing drowsiness, it is sometimes used as a sleep aid. Marijuana is increasingly being considered as a sleep aid, and thought it seems to have initial sleep promoting effects in terms of falling asleep, like alcohol and benzodiazepines, it tends to disrupt sleep architecture and the quality of sleep overall. Additionally, newer research suggests that while occasional use may be useful, long-term use tends to have detrimental effects on sleep.
- There’s no evidence of any negative consequences on health or mortality from insomnia without sleep loss. ↩︎
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I appreciate it when you mentioned that sleep apnea is a condition when the person finds it hard to go to sleep or stay asleep even if they desperately try. My sister has been having that problem for a while now, and it is worrying because her lack of sleep is affecting her studies. She said that her brain won’t let her sleep at night no matter how much milk she drinks or how she tries to relax. Maybe this time, she needs to see a professional.
Logan, yeah with any kind of sleep difficulty is almost always a good idea to get a professional sleep study done to rule out apnea or get someone set up with a CPAP if apnea is present.
Thanks for finally writing about >A Beginner’s Guide to Insomnia | Nick Wignaol <Liked it!
Hi Nick, I got to know you via Medium. I feel so thankful to read your articles as a person who has been struggling with insomnia, anxiety and some social problems these years. Your words make me think and encourage me a lot.
May I ask if I could translate some of your articles into Chinese and published in my own blog (WeChat) sharing with my personal friends? No business purpose of course.
Thanks for the kind words!
And yes, feel free to translate and share. But please credit me as the original author and link back to this piece, if you don’t mind.
Very useful. Thank you 🙂
Great overview Nick! Can you recommend resources/literature for CBT-I?
Thanks for getting me back into the reading again. I really enjoyed the stuff you shared in the form of blogs. Keep writing.
I have been reading your articles with great interest-
I have had insomnia for many many years. I have tried many of the techniques you write about.
Can you recommend a CBTI therapist?
Someone I really recommend is an insomnia coach named Martin Reed: https://insomniacoach.com
Whats your thoughts on the actual neuro pathways of insomnia ie issue with the flip flop model involving the orexin, vlpo and ras. I know people say that insomnia is a product of hyperarousal v sleep drive but how does all this tie together circadian arousing signal sleep drive (adenosine) meltatonin increasing – vlpo inhibiting the ras via gaba. Is there not a bit more to it than straight sleep drive v arousal. Ive hear some researchers talking about a 3 process model to encompass arousal in there.
Would love to hear your thoughts
Nick Wignal changed my life in just a few sessisons. I hadn’t slept well for 13 years, and counting. I had my first session with Nick in March of 2020 the day before the lockdown for covid. His explanation of sleep and assurance that it was not lethal to lose sleep, set me on a course of true sleep and cure for anxiety over it. I followed his instructions, kept at it, and added relaxation every day, and now I sleep almost every night without fail. Occasionally, I get too hyped up to sleep, but hardly ever. Thank you!!
I sent this to your email address, Nick, but maybe this is a more appropriate place …
I’ve been struggling with insomnia for eight months now. I finally decided to hire an online sleep coach to help since I’m struggling to implement CBTI techniques on my own. But … this coach’s “instructional” videos are troubling, saying things like insomnia causes Alzheimer’s, heart disease, and all sorts of terminal illnesses.
Can that be true? I thought I heard that chronic insomnia, in fact, doesn’t cause any major health issues (other than feeling crummy in general and of course having some brain fog from lack of sleep).
This is scary stuff, and I’d like to know if his videos are wrong. If so, I don’t know that I should be using him as my coach going forward. Thanks for any advice you’ve got.