Patient education: Insomnia (Beyond the Basics)
- Michael H Bonnet, PhD
Michael H Bonnet, PhD
- Professor, Department of Neurology
- Wright State University Boonshoft School of Medicine
- Donna L Arand, PhD
Donna L Arand, PhD
- Research Associate Professor
- Wright State University Boonshoft School of Medicine
Insomnia is defined as difficulty falling asleep, difficulty staying asleep, or waking up early in the morning and not being able to return to sleep. In general, people with insomnia sleep less or sleep poorly despite having an adequate chance to sleep. The poor sleep may lead to trouble functioning during the daytime.
Insomnia is not defined by the number of hours slept because "sufficient sleep" can vary from one person to another. Sleep requirements may also decrease with age.
Insomnia is the most common sleep complaint in the United States. While almost everyone has an occasional night of poor sleep, approximately 10 percent of adults have long-term or chronic insomnia.
This article will review the symptoms, causes, and diagnosis of insomnia. Treatment of insomnia is discussed separately. (See "Patient education: Insomnia treatments (Beyond the Basics)".) More detailed information about insomnia is available by subscription. (See "Overview of insomnia" and "Clinical features and diagnosis of insomnia".)
Common symptoms of insomnia include:
●Difficulty falling asleep or staying asleep
●Variable sleep, such as several nights of poor sleep followed by a night of better sleep.
●Daytime fatigue or sleepiness
●Reduced motivation or energy
●Increased errors or accidents
●Ongoing worry about sleep
For many people, the symptoms of insomnia interfere with personal relationships, job performance, and daily function. People who experienced chronic insomnia may also have an increased risk of automobile accidents compared with people who are fatigued for other reasons.
People with insomnia have an impaired sense of sleep. You may feel that you have not slept, even if testing shows that you have. You may also feel more fatigued than individuals without insomnia, even if testing indicates that you are less sleepy. This impaired sense of sleep 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.
One result of poor sleep is that you may become concerned that you will be sleep-deprived and will suffer from serious consequences of lost sleep. This concern may grow as you are unable to sleep, which in turn makes it increasingly difficult to fall asleep. It is important that you not get caught in this cycle and understand that you are sleeping more than it seems.
Insomnia may have many causes (see "Overview of insomnia"):
Short-term insomnia — Short-term insomnia lasts less than three months and is usually associated with stressors. Possible stressors include the following:
●Changes in the sleeping environment (temperature, light, noise)
●The loss of a loved one, divorce, or job loss
●Recent illness, surgery, or sources of pain
●Use or withdrawal from stimulants (caffeine), certain medications (theophylline, beta blockers, steroids, thyroid replacement, and asthma inhalers), illegal drugs (cocaine and methamphetamine), or alcohol
Short-term insomnia often resolves when the stressor resolves.
Situations that disrupt your normal sleep cycle can also cause insomnia. Some examples of this include:
●Jet lag – Traveling across time zones can cause insomnia, known as jet lag. Jet lag may occur regardless of the direction of travel, although it is most pronounced when traveling west to east. Most people require several days to adjust their sleep pattern to the new time zone. Other tips are provided here (table 1).
●Shift work – Individuals who work the night shift commonly experience insomnia. You may be sleepy at work and while driving home in the morning, but have difficulty staying asleep past noon. The sleep problems can be resolved by transferring from the night shift or by sleeping at the same time every day including weekends for several weeks. Shift work sleep disorder and other sleep timing disorders are summarized in the table (table 2).
Long-term insomnia — Long-term (or chronic) insomnia lasts longer than three months and occurs at least three nights per week. Insomnia often occurs with other conditions, including:
●Mental health problems, such as depression, anxiety disorders (including panic attacks), and posttraumatic stress disorder
●Medical illnesses, especially those that cause pain, stress, or difficulty breathing
●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)")
●Medications or illegal drug use
●Irregular sleep habits
Insomnia can also occur on its own. In some cases, it can begin in childhood or be passed along in families.
Short duration sleep and sleep deprivation — Insomnia is frequently confused with short sleep requirement and sleep restriction:
●Sleeping for only a short period of time is common among people who have insomnia. However, some people normally require little sleep and can function without difficulty after sleeping for only a few hours. People who sleep less but have no residual daytime sleepiness or other symptoms are called short sleepers and do not have a sleep problem. In addition, you may need less sleep as you get older. Needing less sleep does not necessarily mean that you have insomnia unless you also have daytime symptoms, such as sleepiness or dysphoria.
●People who have a reduced time in bed (sleep restriction) as well as those with insomnia sleep for a short time and have difficulty functioning during the daytime. However, people who are sleep restricted will fall asleep quickly and sleep normally if given the opportunity. Chronic loss of sleep, caused by spending fewer than eight hours in bed on most nights, is probably the most common cause of sleepiness. Patients with insomnia are unable to sleep normally when they are given the chance to sleep.
If you seek help for insomnia, your doctor or nurse will start by asking you how many hours you slept and what problems you have had with sleep over a typical 24-hour period. Your bed partner or caregiver can help to answer these questions because you may not be aware of what happens while you sleep.
You may be asked to keep a daily sleep log, which is a record of sleep times for one to two weeks.
Your doctor or nurse may ask other questions to determine the cause of your insomnia. A physical examination may be performed to determine if there are medical or neurologic conditions causing or worsening your sleep problems.
Laboratory tests may be recommended to help identify underlying medical or sleep disorders, although this is not required for everyone with insomnia. Laboratory tests may include polysomnography or actigraphy:
●Polysomnography – Polysomnography is a formal sleep study done in a sleep laboratory. It uses monitors that are attached to your body to record movement, brain activity, breathing, and other physiologic functions. This test may be used when an underlying 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, generally worn on the wrist throughout the day and night. The test is conducted over one to two weeks at home to gather estimates about how much and at what time you are sleeping.
The treatment of insomnia is discussed separately. (See "Patient education: Insomnia treatments (Beyond the Basics)".)
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 (Willis-Ekbom disease) (The Basics)
Patient education: Daytime sleepiness (The Basics)
Patient education: Sjögren's syndrome (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.
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
Overview of insomnia
Clinical features and diagnosis of insomnia
Treatment of insomnia
Physiology and available preparations of melatonin
The following organizations also provide reliable health information.
●National Library of Medicine
●American Academy of Sleep Medicine
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.