Everything You Need to Know about Insomnia

1. What Is Insomnia

Insomnia is a common sleep disorder. People who are bothered by it usually have difficulty in falling or staying asleep even in a comfortable environment and bear bad quality of sleep which fail to leave them refreshed when they wake up. And this disorder can be closely related to and interact with the disorders in daytime.

According to the American Sleep Association, nearly 70 million Americans have a sleep disorder and 30% of adults are experiencing short-term insomnia.

And in a report of  the American Journal of Managed Care , insomnia is the most common sleep disorder and a substantial burden for the US healthcare system and vulnerable patient groups. Combined direct and indirect costs for insomnia in the United States exceed $100 billion annually.

Generally, insomnia can be divided into five types: acute insomnia, chronic insomnia, onset insomnia, maintenance insomnia and behavioral insomnia of childhood.

Acute insomnia, the most common type of insomnia, is short-term insomnia that can last from a few days to a few weeks. It usually lasts for less than three months, and symptoms may fade on their own as time passes and a person copes with the stressful incident that gave rise to their sleeping problems. However, short-term insomnia can be persistent and become chronic insomnia. About 30% of American adults are experiencing this kind of disorder. 

Chronic insomnia is also known as long-term insomnia. If a person suffers trouble sleeping at least three days per week for at least one month, his/her insomnia could be chronic. Some people with chronic insomnia have a long history of difficulty sleeping. Inability to get the sleep they need may be persistent or go away and recur with months-long episodes at a time. About 10% of American adults are suffering chronic insomnia. 

Onset insomnia refers to trouble falling asleep whenever sleepers attempt to initiate sleep. Most people with sleep onset problems can’t fall asleep even after spending 20-30 minutes in bed. The direct negative result of onset insomnia is reduction of total sleep time and the tiredness sleepers feel when waking up. This type of insomnia can be short term or chronic. 

Maintenance insomnia describes having difficulty staying asleep throughout the night, or waking up too early and having trouble getting back to sleep. Most often, sleepers with it wake up at least once during the night and are not able to fall back sleep in 30 minutes or even longer.This type of insomnia causes fragmented sleep, meaning a decrease in both sleep quantity and quality. This interferes with sleep further, creating a vicious cycle.

Behavioral insomnia of children (BIC) is a sleep disorder found in children. It is characterized by children having difficulty falling asleep or maintaining sleep leading to poor sleep quality and duration.

Types of BIC include:

Sleep onset association type: Infants and toddlers have a hard time falling asleep or falling back sleep after waking up on their own. Parents may have to do something special, like rocking them or singing a lullaby, to help their sleep onset.

Limit-setting type: Children resist going to sleep at appropriate times. The children may ask to hear more bedtime stories, need another glass of water, or go to the bathroom again to delay bedtime. If they wake up once they are sleeping, they may refuse to return to bed. This usually starts around 2 years of age when children are verbal and able to get out of bed.

Mixed-type: Children can have a combination of both sleep onset association and limit-setting types.

There are approximately 25% of children affected by it. 

The clinical manifestations of insomnia patients mainly include:

Difficulty falling and staying asleep, decreased sleep quality and sleep duration.

Functions of memory, paying attention and planning decline, resulting in sleepiness and reduction in work ability during daytime. Daytime drowsiness is prone to occur when stopping working.

Chest tightness, palpitations, unstable blood pressure, peripheral vasoconstriction and expansion disorders happen to cardiovascular system; constipation or diarrhea, stomach fullness to digestive system; neck and shoulder muscle tension, headache and low back pain to motor system. The ability to control emotions is reduced. And it is easy to get angry or unhappy; men are prone to impotence, and women often show reduced sexual function.

It is prone to lose weight in a short term and to negatively affect immune function and endocrine.

2. What Causes Insomnia?

There are numerous potential causes of insomnia, and in many cases, multiple factors can be involved. Poor sleep can also trigger or worsen other health conditions, creating a vicious cycle for insomnia.

These causes may include:

Stress can do harm to people in many ways, sleep included. Relative studies pointed out that stress can profoundly affect human body, lowering sleep quality.  

Stress may be caused by many factors, like work, study, relationships with surrounding people and even insomnia itself. Ignoring this factor could further foster the interaction between stress and insomnia

Physical illnesses can cause insomnia as the pain can largely torment patients and keep them away from falling asleep or staying asleep.

The elder who are more likely to have health problems is the biggest group to be troubled by insomnia from medical conditions. Next are women as they need to experience pregnancy and menopause.

The severity and duration of insomnia often varies with the related health condition.

The relationship between sleep and mental health is similar with that between sleep and stress as they can interact and promote each other. A 40-year longitudinal follow-up of medical students  found that 41% of patients with both insomnia and mental disorder have insomnia preceding mental disorders, and 29% conversely.

Depression, one of mental disorders, is a frequent cause of insomnia. People with depression often have trouble falling asleep or staying asleep. Difficulty falling asleep is also common in people with anxiety disorders. Other mood disorders such as anxiety and bipolar disorder may also cause sleep problems.

Abuse or inappropriate use of medication can bring various side effects to patients, and insomnia is one of them. Common cold and allergy medicines contain pseudoephedrine, which keeps you awake even if you don not want it to. Antidepressants and medications to treat ADHD, high blood pressure or Parkinson’s disease can also cause insomnia.

In addition to the effect from drug ingredients, medication can cause insomnia in other ways. For instance, taking some drugs can make it difficult to fall asleep or cause you to wake up during the night. When you stop, there may be withdrawal symptoms  that can include insomnia.

Irregular sleep schedules due to jet lag, shift work and other factors can cause insomnia. Theoretically, the body’s internal clock, known as its circadian rhythm , closely follows the daily pattern of day and night. But the reality is many people have sleep schedules that cause misalignment of their circadian rhythm.

Caffeine and alcohol, as a part of some people’s daily habits, can also contribute to insomnia. Caffeine is a stimulant that can stay in your system and keep you excited for hours. Taking caffeine at noon and night can postpone people’s desire to sleep until deep night. Alcohol can make you feel sleepy at the beginning. However, it can also worsen your sleep by disturbing your sleep cycle and causing fragmented, non-restorative sleep.

The sleep environment can cause insomnia. Factors like noise, light or temperature can affect sleep positively or negatively. A quiet and dark room with proper temperature is, out of question, perfect for sleep onset. But filling the room with some sleep-inducing noises and light could also be conductive, especially for those who already have insomnia and other sleep disorders.

Some sleep disorders can cause insomnia or make it worse. For instance, people with restless legs syndrome may have a hard time falling asleep.

3. Treatments for Insomnia

Treating insomnia typically involves sleep-inducing medication, cognitive behavioral therapy for insomnia (CBT-i), or a combination of both. Besides, positive changes in other factors, like lifestyle, sleep schedule and sleep environment, may alleviate symptoms for some people, as well. There is no best treatment for insomnia as it is largely depend on individuals.

CBT-i is considered a first-line treatment for insomnia because it does not carry the health risks associated with sleep medication. In most cases, CBT-i is provided by a licensed psychologist who has received training for this type of treatment. CBT-i focuses on pinpointing the anxieties people with insomnia often have about sleep, and then replacing these anxieties with healthier beliefs and attitudes.

CBT-i comprises several well-established therapeutic strategies:

Sleep education and hygiene: Educate patients on information about healthy sleep and  methods to increase behaviors and environmental conditions that are conductive to a sound sleep.

Stimulus control: Help patients reduce their anxieties a the thought of sleep and build a healthy relationship between their sleep and environment.

Sleep restriction and compression: Partially deprive sleep and reduce the time patients spend on the bed when they are awake to activate the sleep drive, the positive beginning of high-quality sleep.

Relaxation: Use a series of relaxation techniques, such as diaphragmatic breathing, biofeedback, imagery and meditation, to reduce patients’ levels of physiologic and cognitive arousal.

While CBT-i may be more beneficial for chronic insomnia, medications may be more suggested for short-term insomnia treatment. Currently, a range of medications are commonly used: sedating antidepressants, melatonin, benzodiazepine receptor agonists. Medications can almost solve sleep problems in a short term, but they can lose effectiveness over time. Nevertheless, hypnotic medications should be considered for acute treatments for insomnia or when behavioral treatments are unsuccessful.

Improving the defective factors causing insomnia can also help alleviate insomnia in some degree. For those who are addicted to caffeine intake, certain reduction of it or keeping it only in the morning are suggested. Maintaining a regular sleep schedule can help reduce insomnia related to circadian rhythm. Setting a warm ambiance of the bedroom with personally preferred elements, like light, sounds or a fuzzy bed, can also promote sleep onset and improve sleep quality.