Sleep Disorder: Insomnia
Insomnia is a common sleep disorder or sleep condition where you:
have difficulty falling asleep, or
you have trouble staying asleep, or
you wake up too early in the morning; and
your sleep problems affect you during the day.
Insomnia may be acute (lasting a few nights or weeks), short-term (more than a month) or chronic (more than three months).
Chronic insomnia can also come and go over many years with sleep problems that last several days or weeks but never having a single episode that lasts 3 months or longer.
How Common Is Insomnia?
Insomnia is the most common of the sleep disorders and the second most common overall problem (after pain) reported to doctors in primary care settings.
Around 30–50 % of adults report sleep trouble in a given year.
It is generally accepted in sleep medicine that roughly 1/3 of adults will often have trouble falling sleep, staying asleep, or overall poor sleep quality.
Around 10% of people will experience insomnia chronically that also causes daytime fatigue and other problems.
Insomnia Symptoms: What Are Common Symptoms Of Insomnia?
People experiencing symptoms often report:
Trouble getting to sleep (sleep onset);
Difficulty staying asleep (sleep maintenance);
Early morning awakenings;
Fatigue and/or exhaustion;
Troubles with attention, concentration, or memory;
Difficulty with family obligations or social, school, or work performance;
Irritability and mood disturbance;
Inability to fall asleep during the day (common);
Sleepiness during the day (uncommon, typically only older adults 55+ yrs)
Issues with behavior such as aggression, impulsivity, or hyperactivity;
Tendency to make errors or cause accidents;
Decreased energy and motivation or lack of initiative;
Dissatisfaction and complaints about sleep quality.
Mental health complaints like anxiety and depression are also common. Sleep issues often occur with depression, with around 70% of those with depression having insomnia before their depression. Anxiety disorders are also common.
What Are The Types Of Insomnia?
The International Classification of Sleep Disorders-3rd edition (ICSD-3) has three types of insomnia:
Chronic Insomnia;
Short-term Insomnia; and
Other insomnia disorder.
Other forms that are referred to on some of Google's top results for insomnia (e.g. WebMD) are outdated.
These outdated terms include types such as primary insomnia and secondary insomnia, as well as subtypes such as comorbid, psychophysiological, inadequate sleep hygiene, idiopathic, and paradoxical insomnia. These sub-types are now all considered to be chronic insomnia.
What Are The Risk Factors For Developing Insomnia?
Scientific studies have found the following factors can contribute to developing insomnia:
Female sex (the female to male ratio is 1.5/1)
Elderly age (older people tend to have poorer sleep than younger people)
Family history (heritability of insomnia is between 30%- 60%)
Emotionally reactive personality
Ethnocultural (Whites & Blacks more likely than Hispanics & Asians)
Unemployment
Low socioeconomic status
Marital status (single, widowed, divorced)
Noisy environments
Psychosocial stressors
Poor physical health
Substance abuse
Congestive heart failure
Sleep-disordered breathing conditions such as obstructive sleep apnoea
Back and hip problems, and
Prostate problems
Chronic pain
Jetlag
What Are The Causes Of Insomnia?
While there are many possible causes, studies have found that the most typical insomnia causes are general stressful life events related to health, family, relationships, work or school or medical conditions.
Insomnia Complications: How Does Insomnia Affect Human Health?
Insomnia impacts both physical and mental health. Some of the common health consequences are:
Impaired quality of life
Isolation & inability to engage fully in work & social life
Irritability
Fatigue and low energy
Hypertension
Heart attack
Substance abuse
Absenteeism and work disability
Numerous long term studies show that a history of insomnia is associated with a greater risk of future depressive (approx. two-fold increase in risk), anxiety, and substance use disorders..
Persistent insomnia has been shown to be an independent risk factor for suicide.
Problems like hypertension and heart attacks are increased in people with insomnia.
The strongest evidence for cardiovascular and metabolic complications of insomnia has been found in individuals with objective short sleep duration (<6 hours).
How Do I Know If I Have Insomnia?
You may have insomnia if you have one or more of the following sleep problems:
Trouble falling asleep;
Trouble getting back to sleep after awakening; or
You find you wake too early and struggle to get back to sleep;
Your sleep issues are affecting your daytime functioning.
Insomnia is actually a subjective sleep disorder. That means that, to a degree, it’s determined by you, the individual, and the level of distress you feel about your sleep problems, whether you are getting enough sleep or getting the sleep you need, rather than a sleep test or sleep study taken in sleep centre or lab.
How Is Insomnia Diagnosed?
The diagnosis of insomnia is done through a clinical interview or assessment interview with a sleep specialist. Diagnosis does not require any overnight sleep test such as polysomnography in a lab or a home sleep test.
The sleep specialist will use one of the two main classification systems for diagnosing.
Diagnostic criteria for insomnia is found in the International Classification of Sleep Disorders, 3rd edition (ICSD-3) and another set is in the Diagnostic & Statistical Manual of Mental Disorders, 5th edition (DSM-5). A clinician could use either and the core symptoms in both classifications are:
Difficulty falling to sleep; and/or
Difficulty staying asleep (i.e., frequent awakenings or problems returning to sleep after awakenings); and/or
Early-morning awakening with the inability to return to sleep.
The sleep difficulties occurs on at least 3 or more nights per week.
The sleep difficulties have lasted at least 3 months.
The sleep disturbance causes clinically significant distress (e.g. fatigue, decreased energy, mood problems, worries about sleep loss) OR impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
The sleep difficulty occurs despite adequate opportunity [e.g., lasting at least 7 hours] for sleep
The sleep difficulty is not attributable to the effects of a substance (e.g., a drug of abuse, a medication).
If you feel you meet these criteria, then you can assess how serious your symptoms are using our online insomnia test.
What Does A Diagnostic Assessment Interview For Insomnia Involve?
A diagnostic assessment interview should involve a comprehensive sleep history including identifying any physical health and mental health conditions.
The sleep history includes a review of nighttime and daytime symptoms as well as habits and routines throughout the day and night. Other sleep conditions are reviewed and if another sleep disorder is identified (for example, circadian rhythm problems are often mistaken for insomnia in adolescence). A range of assessment questionnaires may also be required.
The assessment interview should be supplemented with a request for you to keep a sleep diary to assess your sleep patterns, including when you go to bed, amount of sleep, wake ups etc. In some rare situations there could be objective testing with actigraphy or a sleep study.
What Are Insomnia Treatment Options?
Treatment options for insomnia include behavioural treatments (most effective), medications (help with short term symptom relief), sleep hygiene advice (not helpful for chronic sufferers) and sleep aids and supplements (ineffective).
What Is Cognitive Behavioral Therapy for Insomnia, CBTi or CBT-i?
Cognitive behavioural therapy for insomnia or CBTi is the recommended first-line treatment of insomnia by The American Academy of Sleep Medicine and virtually all Colleges of General Practice (GP) Medicine around the world.
CBT-i is a form of Cognitive Behaviour Therapy tailored towards treating underlying issues contributing to insomnia. Unlike other forms of CBT, this means targeting any physiological imbalances in a person's sleep/wake system that can be present, as well as sleep-related neurocognitive and emotional factors.
How Much Does CBT For Insomnia Help With Insomnia?
Scientific studies have shown that around 90% of people treated using CBTi will experience clinically significant improvements in sleep. Around 70-80% will experience restoration of normal sleep, and around 50% of people will have complete remission.
Read our comprehensive primer on cognitive behavior therapy for insomnia here.
What Are Medication Or Pharmacological Treatments For Insomnia?
Several medicines are commonly used in treating insomnia. These medications do not address underlying causes of insomnia and prolonged use can lead to sleeping pill addiction. So medical colleges recommend only using sleeping pills for a short time to allow you to re-establish a regular sleep schedule.
Not all medications are available across different countries.
Common prescription sleep medicines, also known as sleeping pills include drugs of the benzodiazepine class such as:
Temazepam (Restoril)
Triazolam (Halcion)
Estazolam
Alprazolam (Xanax)
Clonazepam (Klonopin)
Diazepam (Valium)
Lorazepam (Atvian)
Similar but non-benzodiazepine medicines known as “Z-drugs”:
Zopiclone (Imovane)
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopiclone (Lunesta)
Low dose anti-depressants can be indicated as sleep medications:
Doxepin (Silenor)
Newer classes of medications know as melatonin receptor agonists are available in some countries:
Ramelteon (Rozerem)
As are orexin receptor antagonists:
Suvorexant (Belsomra)
Anti-depressants, anti-psychotics, and anti-convulsants can also be prescribed as sleep medications, typically in lower doses than prescribed for other conditions.
What Are The Natural Sleep Aids & Supplements Used To Treat Insomnia?
There are a wide variety of natural herbal remedies, sleep aids and supplements sold as insomnia treatments that can improve sleep. These include:
Magnesium
Valerian
Kavakava
Passionflower
Research shows that these sleep aids have little to no benefit in insomnia treatment.
In the near future we intend to offer a comprehensive review of evidence for different natural sleep supplements and herbal remedies and provide a dispensary for herbal supplements for sleep that actually work and the clinical evidence for their effectiveness.
Can Changing Sleep Habits Help?
Online sources and most medical practitioners will advise on lifestyle changes, including identifying and changing poor sleep habits and sleep routines, known as sleep hygiene, in the belief that these factors interfere with your sleep. Typical sleep hygiene advice involves things like cutting out behaviours that keep you from falling asleep such as stimulating activities before bed.
This could help you sleep better and relieve acute insomnia. However, it is well established in sleep medicine that sleep habits and sleep hygiene will not be sufficient to treat chronic insomnia in adults. It also will not work in around 50% of short term cases as evidence shows around 50% of short term cases become chronic insomnia disorder. This kind of advice simply does not address underlying causes of your sleep problems.
In fact, if you have good sleep hygiene and still have trouble falling asleep or staying asleep then you could have a sleep disorder and should seek to be referred to a sleep clinic or referred to a sleep specialist (or self-refer). Take our sleep hygiene quiz here.
Frequently Asked Questions
Is An Overnight Sleep Study Or Polysomnograph Study Needed To Diagnose Insomnia?
No. An insomnia diagnosis does not require an overnight sleep study. Insomnia is diagnosed via an interview with a sleep specialist.
Do I Have Insomnia If My Sleep Problems Have Been Going On Less Than Three Months?
If a person meets all the insomnia symptoms listed in either the ICSD-3 or DSM-5 but their difficulties have lasted less than 3 months then the ICSD-3 has a classification of ‘short-term insomnia’. The DSM-5 would label this ‘other specified insomnia disorder’.
If you feel you meet these criteria, then you can assess how serious your symptoms are using our free online sleep insomnia test.
Why Are There Two Different Insomnia Classifications?
There are two different classifications of insomnia because it is considered both:
A sleep disorder treated by a behavioural sleep medicine specialist (and therefore listed in the sleep specialist’s primary text - The International Classification of Sleep Disorders, 3rd edition, ICSD-3); and
A psychological/mental health disorder treated by an appropriately trained sleep psychologist (and therefore listed in the mental health practitioner’s primary text - The Diagnostic & Statistical Manual of Mental Disorders, 5th edition, DSM-5).
What Kind Of Sleep Disorder Is Insomnia?
Insomnia is one of the sleep conditions that fit in the broad category of sleep disorders known as dyssomnias. Dyssomnias are characterized by abnormal changes in amount or how much sleep one gets, quality of sleep, or timing of sleep.
Written By: The Better Sleep Clinic Team
Reviewed By: Dan Ford, Sleep Psychologist