At a glance......
- 1 Types of Insomnia
- 2 According to Severity
- 3 Causes of Insomnia
- 4 Who gets insomnia?
- 5 Symptoms of Insomnia
- 6 Diagnosis of Insomnia
- 7 References
Insomnia Types Causes Symptoms a common sleep disorder that can make it hard to fall asleep, hard to stay asleep or cause you to wake up too early and not be able to get back to sleep. You may still feel tired when you wake up. Insomnia can sap not only your energy level and mood but also your health, work performance and quality of life.
Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality that is associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, and/or awakening earlier in the morning than desired. Although progress has been made in our understanding of the nature, etiology, and pathophysiology of insomnia, there is still no universally accepted model. Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment. most every night.
Insomnia is the most common sleep disorder affecting millions of people as either a primary or comorbid condition. Insomnia has been defined as both a symptom and a disorder, and this distinction may affect its conceptualization from both research and clinical perspectives. However, whether insomnia is viewed as a symptom or a disorder, it nevertheless has a profound effect on the individual and society. The burden of medical, psychiatric, interpersonal, and societal consequences that can be attributed to insomnia underscores the importance of understanding, diagnosing, and treating the disorder[Rx]
Types of Insomnia
Insomnia includes a wide range of sleeping disorders, from lack of sleep quality to lack of sleep quantity.
The International Classification of Sleep Disorders 2[Rx] codes insomnia under the broad heading of dyssomnias, either intrinsic or extrinsic sleep disorders. Based on the severity, it classifies insomnia into three types as follows.
Mild insomnia – This term describes an almost nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by little or no evidence of impairment of social or occupational functioning. Mild insomnia is often associated with feelings of restlessness, irritability, mild anxiety, daytime fatigue, and tiredness.
Moderate insomnia – This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by mild or moderate impairment of social or occupational functioning. Moderate insomnia is always associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.
Severe insomnia – This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by severe impairment of social or occupational functioning. Severe insomnia is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.
According to Severity
- Transient insomnia – occurs when symptoms last from a few days to a few weeks.
- Acute insomnia – also called short-term insomnia. Symptoms persist for several weeks.
- Chronic insomnia – this type lasts for months, and sometimes years. According to the National Institutes of Health, the majority of chronic insomnia cases are secondary, meaning they are side effects or symptoms resulting from another primary problem.
Although insomnia can affect people of any age, it is more common in adult females than adult males. The sleeping disorder can undermine school and work performance, as well as contributing to obesity, anxiety, depression, irritability, concentration problems, memory problems, poor immune system function, and reduced reaction time.
Insomnia has also been associated with a higher risk of developing chronic diseases.
According to the National Sleep Foundation, 30-40 percent of American adults report that they have had symptoms of insomnia within the last 12 months, and 10-15 percent of adults claim to have chronic insomnia.
Before thinking about disturbed sleep, it’s important to understand what normal sleep really is. Normal slumber involves falling asleep relatively easily once you’re in bed, Silberman said. “People have a range of how quickly they go to sleep,” she said, but typically they can drift off to sleep anywhere from a few minutes to 15 minutes.
Normal sleepers will also go through four stages of sleep several times a night, she said. According to The Insomnia Workbook, the stages are:
- Stage N1 – the lightest stage, which usually makes up 10 percent of your total sleep time.
- Stage N2 – unlike stage N1, you lose awareness of external stimuli, and people spend most of their sleep time in this stage.
- Stage N3 – known as slow-wave sleep, and believed to be the most restorative.
- Stage R – known as REM sleep, or rapid eye movement. It’s the most active of the stages for your brain and body functions, such as breathing and heart rate. Your muscles relax, however, so you don’t act out your dreams.It’s also normal for it to take about 20 to 30 minutes to feel truly awake in the morning.
Causes of Insomnia
Symptoms of insomnia can be caused by or be associated with:
- Use of psychoactive drugs (such as stimulants), including certain medications, herbs, caffeine, nicotine, cocaine, amphetamines, methylphenidate, aripiprazole, MDMA, modafinil, or excessive alcohol intake.
- Use of or withdrawal from alcohol and other sedatives, such as anti-anxiety and sleep drugs like benzodiazepines.
- Use of or withdrawal from pain-relievers such as opioids.
- Previous thoracic surgery.
- Heart disease.
- Deviated nasal septum and nocturnal breathing disorders.
- Restless legs syndrome, which can cause sleep onset insomnia due to the discomforting sensations felt and the need to move the legs or other body parts to relieve these sensations.
- Periodic limb movement disorder (PLMD), which occurs during sleep and can cause arousals of which the sleeper is unaware.
- Pain, an injury or condition that causes pain can preclude an individual from finding a comfortable position in which to fall asleep and can in addition cause awakening.
- Hormone shifts such as those that precede menstruation and those during menopause.
- Life events such as fear, stress, anxiety, emotional or mental tension, work problems, financial stress, the birth of a child, and bereavement.
- Gastrointestinal issues such as heartburn or constipation.
- Mental disorders such as bipolar disorder, clinical depression, generalized anxiety disorder, post traumatic stress disorder, schizophrenia, obsessive compulsive disorder, dementia, and ADHD.
- Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Chronic circadian rhythm disorders are characterized by similar symptoms.
- Certain neurological disorders, brain lesions, or a history of traumatic brain injury.
- Medical conditions such as hyperthyroidism and rheumatoid arthritis.
- Abuse of over-the-counter or prescription sleep aids (sedative or depressant drugs) can produce rebound insomnia.
- Poor sleep hygiene, e.g., noise or over-consumption of caffeine.
- A rare genetic condition can cause a prison-based, permanent and eventually fatal form of insomnia called fatal familial insomnia.
- Physical exercise. Exercise-induced insomnia is common in athletes in the form of prolonged sleep onset latency.
Sleep studies using polysomnography have suggested that people who have sleep disruption have elevated nighttime levels of circulating cortisol and adrenocorticotropic hormone. They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study. Studies of brain me
- Disruptions in circadian rhythm – jet lag, job shift changes, high altitudes, environmental noise, heat, or cold.
- Psychological issues – people with mood disorders such as bipolar disorder, depression, anxiety disorders, or psychotic disorders are more likely to have insomnia.
- Medical conditions – brain lesions and tumors, stroke, chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease (GERD), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson’s and Alzheimer’s diseases, hyperthyroidism, arthritis.
- Hormones – estrogen, hormone shifts during menstruation.
- Other factors – sleeping next to a snoring partner, parasites, genetic conditions, overactive mind, pregnancy.
- Media technology in the bedroom – researchers from the University of Helsinki, Finland, reported in the journal BMC Public Health that media technology in the bedroom disrupts sleep patterns in children. They found that children with TVs, computers, video games, DVD players, and mobile phones in their bedrooms slept considerably less than kids without these devices in their bedrooms. In addition, a study conducted by Rensselaer Polytechnic Institute found that back-lit tablet computers can affect sleep patterns.
Medications – according to the American Association of Retired Persons (AARP), the following medications can cause insomnia in some patients
- Corticosteroids – used for treating patients with allergic reactions, gout, Sjögren’s syndrome, lupus, rheumatoid arthritis, and inflammation of the muscles and blood vessels. Examples include prednisone, triamcinolone, methylprednisolone, and cortisone.
- Statins – medications used for treating high cholesterol levels. Examples include simvastatin, rosuvastatin, lovastatin, and atorvastatin.
- Alpha blockers – used for treating hypertension (high blood pressure), Raynaud’s disease and BPH (benign prostatic hyperplasia). Examples include terazosin, silodosin, alfuzosin, prazosin, doxazosin, and tamsulosin.
- Beta blockers – used for treating hypertension and irregular heartbeat (arrhythmias). Examples include carvedilol, propranolol, atenolol, metoprolol, and sotalol.
- SSRI antidepressants – used for treating depression. Examples include fluoxetine, citalopram, paroxetine, escitalopram, and sertraline.
- ACE inhibitors – used for the treatment of hypertension and other heart conditions. Examples include ramipril, fosinopril, benazepril, enalapril, lisinopril, and captopril.
- ARBs (Angiotensin II-receptor blockers) – used for treatment of hypertension (generally when patient cannot tolerate ACE inhibitors). Examples include candesartan, valsartan, and losartan.
- Cholinesterase inhibitors – used for treating memory loss and other symptoms in patients with dementia, including Alzheimer’s disease. Examples include rivastigmine, donepezil, and galantamine.
- Second generation (non-sedating) H1 agonists – used for treating allergic reactions. Examples include loratadine, levocetirizine, desloratadine, and cetirizine.
- Glucosamine/chondroitin – dietary supplements used for relieving the symptoms of joint pain and to reduce inflammation.
Who gets insomnia?
Shift workers commonly suffer from insomnia because of inconsistent sleep routines.
Some people are more likely to suffer from insomnia than others; these include:
- Shift workers with frequent changes in shifts (day vs. night)
- The elderly
- Drug users
- Adolescent or young adult students
- Pregnant women
- Menopausal women
- Those with mental health disorders
Symptoms of Insomnia
Insomnia itself may be a symptom of an underlying medical condition. However, there are several signs and symptoms that are associated with insomnia:
- Difficulty falling asleep at night
- Waking during the night
- Waking earlier than desired
- Still feeling tired after a night’s sleep
- Daytime fatigue or sleepiness
- Irritability, depression, or anxiety
- Poor concentration and focus
- Being uncoordinated, an increase in errors or accidents
- Tension headaches (feels like a tight band around head)
- Difficulty socializing
- Gastrointestinal symptoms
- Worrying about sleeping
Sleep deprivation can cause other symptoms. The afflicted person may wake up not feeling fully awake and refreshed and may have a sensation of tiredness and sleepiness throughout the day. Having problems concentrating and focusing on tasks is common for people with insomnia.
According to the National Heart, Lung, and Blood Institute, 20 percent of non-alcohol related car crash injuries are caused by driver sleepiness.
At least one of the following forms of daytime impairment related to the nighttime sleep difficulty is reported by the patient:
Diagnosis of Insomnia
|(References: Buysse(Buysse, 2005Rx); Sateia et al. (Sateia et al., 2000Rx))|
|Cardiovascular||congestive heart failure, arrythmia, coronary artery disease|
|Neurologic||stroke, Parkinson’s disease, neuropathy traumatic brain injury|
|Renal||chronic renal failure|
|Rheumatologic||rheumatoid arthritis, osteoarthritis, fibromyalgia, headaches|
|Restless legs syndrome|
|Periodic limb movement disorder|
|Circadian rhythm disorder|
|Nocturnal panic attacks|
|REM behavior disorder|
|Post-traumatic stress disorder|
|DSM IV TR criteria of primary insomnia|
|These include any of the following:|
A sleep specialist will usually begin a diagnostic session by asking a battery of questions about the individual’s medical history and sleep patterns. A physical exam may be conducted to look for conditions that could be causing insomnia. Similarly, doctors might screen for psychiatric disorders and drug and alcohol use.
The Stanford Center for Sleep Sciences and Medicine explains that the term “insomnia” is often used colloquially in reference to “disturbed sleep.”
- For somebody to be diagnosed with an insomnia disorder, their disturbed sleep should have persisted for more than 1 month. It should also negatively impact the patient’s wellbeing, either through the distress that results or the disturbance in mood or performance.
- A sleep specialist is trained to determine whether the symptoms are being caused by an underlying condition. The patient may be asked to keep a sleep diary to help understand their sleeping patterns.
- More sophisticated tests may be employed, such as a polysomnograph, which is an overnight sleeping test that records sleep patterns. In addition, actigraphy may be conducted, which uses a small, wrist-worn device called an actigraph to measure movement and sleep-wake patterns.
The DSM-5 criteria for insomnia include the following
Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
- Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
- Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
- Early-morning awakening with inability to return to sleep.
- The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
- The sleep difficulty occurs at least 3 nights per week.
- The sleep difficulty is present for at least 3 months.
- The sleep difficulty occurs despite adequate opportunity for sleep.
- The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
- The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
- Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
Use of prescription drugs
- Various prescription drugs may be responsible for chronic insomnia. Such a use should be asked for specifically and ruled out. The drugs may include anticonvulsants such as phenytoin and lamotrigine, beta-blockers like acebutolol, atenolol, metoprolol, oxprenolol, propranolol, and sotalol, antipsychotics like sulpiride, antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) or Monoamine oxidase inhibitors (MAOIs) and non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, diclofenac, naproxen, and sulindac.
Sleep diary or sleep log
- A sleep diary helps in specifically estimating the severity of the problem, the night to night variability, and presence of maladaptive habits such as taking naps or spending excessive time in bed (more than 8 hours). Sleep diary also keeps track of compliance with behavioral interventions and response to treatment.
Sleep and psychological rating scale
- Epworth Sleepiness Scale (ESS) rates the chance of dozing in the following situations which may be during sitting and reading, watching television, sitting inactively in a public place, being a passenger in a car for an hour without a break, during lying down to rest in the afternoon, sitting and talking to someone, sitting quietly after lunch without alcohol or while waiting at a traffic signal in a car.
The ESS is rated on a 4-point scale for each of the above factors based on the following scores:
- 0 – no chances of dozing;
- 1 – slight chances of dozing;
- 2 – moderate chances of dozing; and
- 3 – high chances of dozing.
A score of more than 16 indicates daytime somnolence, while a cutoff of 11 is often employed to indicate a possible disorder associated with excessive sleepiness.
Focused physical examination
- A general physical examination may help assess certain organic pathologies such as chronic obstructive pulmonary diseases (COPD), asthma, or restless leg syndrome which may disturb sleep.
- Blood tests may help to rule out subtle manifestations of thyroid diseases, iron deficiency anemia, and vitamin B12 deficiency (restless leg syndrome).
- It is considered the gold standard for measuring sleep. electroencephalogram (EEG), electrooculography (EOG), electromyography (EMG), electrocardiography (ECG), pulse oximetry, and air flow are used to reveal a variety of findings like periodic limb movement disorder, sleep apnea, and narcolepsy.[Rx]
- Actigraphy measures physical activity with a portable device (usually including an accelerometer) worn 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. This approach to estimating sleep and wake time has been shown to correlate with polysomnographic measures in normal sleepers, with reduced values noted in patients with insomnia.[Rx,Rx]
Summary of investigations
- Investigations do not always correlate well with the patient’s experience of insomnia and cannot replace a thorough clinical evaluation. Hence, it is important to recognize that insomnia is a subjective clinical diagnosis, and therefore, a patient’s subjective report of sleep difficulties should play the most important role in directing management in most cases.
- It is also important to ask questions about the range of symptoms experienced and changes over time. Because insomnia is a patient-reported symptom, rather than a polysomnographically defined disorder, referral to a sleep laboratory for polysomnographic diagnosis should be reserved for cases in which another primary sleep disorder, such as obstructive sleep apnea or periodic movement disorder, is suspected, because these may require greater expertise in sleep medicine.[Rx] Other measures that can be used are an evaluation of mental status, subjective sleep quality, psychological assessment scales, daytime function, quality of life, and dysfunctional beliefs and attitudes.