Insomnia

Key Points on Insomnia Disorder

• Insomnia disorder is defined not just by difficulty sleeping, but by the combination of a persistent sleep problem, adequate opportunity for sleep, and resulting daytime impairment (American Academy of Sleep Medicine, 2014).

• The condition often becomes chronic due to "perpetuating factors"—unhelpful behaviors and negative thoughts developed in response to initial sleep loss—rather than the original trigger itself (Spielman et al., 1987).

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment. Studies show 70-80% of people experience a restoration of normal sleep, and around 50% achieve complete remission (Morin et al., 2006a).

• While medications can be used for short-term relief, many have side effects and potential for tolerance or dependence. The choice of medication depends on the specific type of insomnia and individual patient characteristics (During, 2021).

An Overview of Insomnia Disorder

Chronic insomnia is a common condition where an individual has persistent difficulty with the timing, quality, or amount of their sleep, even when they have enough time and a proper environment to rest. This sleep disruption then leads to some form of daytime impairment (American Academy of Sleep Medicine, 2014). At its core, the diagnosis is based on a person's dissatisfaction with their sleep and the negative consequences this has on their daily life (Neubauer, 2021). Modern diagnostic guides, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), have moved away from distinguishing between "primary" (occurring on its own) and "secondary" (caused by another issue) insomnia. Instead, insomnia is now recognized as a distinct disorder that often co-exists with other medical or mental health issues and requires its own specific attention (American Psychiatric Association, 2013).

Understanding insomnia is about more than just counting hours of lost sleep; it involves appreciating how those sleep difficulties affect a person's mood, energy, and ability to function during the day.

But what are the specific criteria that define this common and often distressing condition?

What Is Insomnia Disorder?

Insomnia disorder is formally defined by several key components: an individual's personal report of a sleep problem, the presence of daytime consequences, and having an adequate opportunity to sleep. Unlike just a few nights of poor sleep, insomnia disorder is a persistent condition where sleep difficulty occurs despite having a comfortable environment and setting aside enough time to rest.

The sleep complaint itself can show up in a few different ways:

• Difficulty initiating sleep: Trouble falling asleep at the beginning of the night.

• Difficulty maintaining sleep: Waking up frequently during the night with trouble returning to sleep.

• Early morning awakening: Waking up earlier than desired and being unable to fall back asleep.

For insomnia in children,, this can also include resisting bedtime or having difficulty sleeping without a parent or caregiver present.

For a diagnosis of chronic insomnia disorder, these issues must occur at least three times per week and have been present for at least three months.

It's important to note that chronic insomnia can also be recurrent, with episodes lasting several weeks at a time over many years, without a single continuous episode lasting three months (American Academy of Sleep Medicine, 2014).

Are There Types Of Insomnia?

You may see outdated terms like "primary insomnia," "secondary insomnia," or subtypes like "psychophysiological" or "paradoxical" insomnia online. Modern sleep medicine no longer uses these distinctions, as research has shown that the features of these supposed subtypes overlap significantly and are present in most people with chronic insomnia. Today, these are all considered part of the single diagnosis of chronic insomnia disorder.

Now that we know what the disorder is, just how many people are affected by it?

How Common Is Insomnia Disorder?

Insomnia is the most common sleep disorder and the second most common overall health problem (after pain) that people report to their primary care doctors (Ebben & Spielman, 2014).

Insomnia symptoms are very common, with about 30%-50% of adults reporting at least a brief period of difficulty with sleep in a given year. However, not everyone with symptoms meets the criteria for a formal disorder.

When applying the specific diagnostic criteria, the prevalence is:

• Chronic Insomnia Disorder: Approximately 10% of the general population meets the criteria for chronic insomnia disorder that causes daytime problems.

• Short-Term Insomnia Disorder: Around 15%-20% of people experience a short-term insomnia disorder.

Prevalence of diagnosable chronic insomnia in New Zealand is similar to other developed countries, with studies suggesting approximately 10–15% of adults in NZ meet the criteria for chronic insomnia disorder.

The risk for insomnia is not the same for everyone. It is more common in women, who experience it at a rate about 1.5 times greater than men. The likelihood of having insomnia also increases with age, often due to age-related changes in sleep patterns, a higher rate of co-existing medical conditions, and greater medication use. People with a lower socioeconomic status and those with chronic medical or mental health disorders also have a higher risk of insomnia. 

With so many people affected, what are the underlying factors that put someone at risk?

What Causes Insomnia Disorder? What Are the Risks That Make It More Likely?

Insomnia disorder is best understood through the "3P model," a framework that outlines three sets of factors contributing to its development and persistence: predisposing, precipitating, and perpetuating (Spielman et al., 1987).

While people look for common causes of insomnia, chronic or long-term insomnia is rarely caused by a single factor; rather, it's the interaction between these three that leads to a chronic sleep problem.

• Predisposing Factors: These are underlying vulnerabilities that increase a person's risk of developing insomnia. They don't cause insomnia on their own but set the stage for it.

• Precipitating Factors: These are the acute events or triggers that start an episode of insomnia. Common triggers include stressful life events related to health, work, finances, or family relationships.

• Perpetuating Factors: These are the most important factors in the transition from a few bad nights to a chronic problem. They are the unhelpful habits, thoughts, and beliefs that a person adopts to cope with sleep loss, but which end up making the problem worse.

Common risk factors that can predispose or precipitate insomnia include:

• Female sex

• Older age

• Family history of insomnia (heritability is estimated between 30%-60% (Heath et al., 1990; Hublin et al., 2011))

• An emotionally reactive personality or tendency to worry

• Shift work

• Unemployment or low socioeconomic status

• Marital status (being single, widowed, or divorced)

• Psychosocial stressors

• Poor physical or mental health (e.g., chronic pain, depression, anxiety)

• Other sleep disorders like obstructive sleep apnea

The most common perpetuating factors are behaviors like spending too much time in bed, napping during the day, and developing a conditioned anxiety about sleep itself.

These factors explain why insomnia can persist for years, long after the initial trigger has resolved.

So, how do these underlying causes manifest as symptoms?

Insomnia Symptoms: What Are the Signs and Symptoms of Insomnia Disorder?

The signs and symptoms of insomnia disorder include both nighttime complaints and the daytime consequences that result from poor sleep. A key feature is the feeling of being "tired but wired," where individuals feel exhausted yet are unable to sleep during the day and may even experience a sense of being on high alert, a state known as hyperarousal (Bonnet & Arand, 2010).

The symptoms can be broken down into two main categories:

1. Nighttime Symptoms: The primary complaint is dissatisfaction with sleep quality or quantity, which includes one or more of the following:

• Difficulty Initiating Sleep: Taking a long time to fall asleep.

• Difficulty Maintaining Sleep: Waking up often or for long periods during the night and having trouble getting back to sleep.

• Early Morning Awakening: Waking up much earlier than desired and being unable to fall back asleep.

2. Daytime Consequences: At least one daytime symptom related to the sleep difficulty must be present. These commonly include:

• Fatigue, a general feeling of discomfort, or a lack of energy.

• Problems with attention, concentration, or memory.

• Mood disturbance, such as irritability.

• Daytime sleepiness (though many people with insomnia are unable to nap despite feeling tired).

• Behavioral problems, such as hyperactivity or impulsivity (more common in children).

• Reduced motivation or initiative.

• Being more prone to errors or accidents.

• Having significant concerns or feeling dissatisfied with sleep.

Mental health complaints are also common.

Sleep issues often occur with depression, with some research suggesting that around 70% of those with depression experience insomnia before their depression begins.

The presence of these daytime impairments is what separates insomnia disorder from simply being a "short sleeper" or having an occasional poor night's sleep.

But with such a personal experience, how is the disorder formally diagnosed?

Insomnia Diagnosis: How Is Insomnia Disorder Diagnosed?

The diagnosis of insomnia disorder is based almost entirely on a patient's personal report and clinical history; there is no objective blood test or brain scan for insomnia. The process relies on a comprehensive evaluation to confirm that diagnostic criteria are met and to rule out other conditions that could be causing the sleep problem (Schutte-Rodin et al., 2008).

The key steps in diagnosis include:

• Comprehensive Clinical History: This is the foundation of the diagnosis. A clinician will conduct a detailed interview about the patient's sleep patterns, daytime symptoms, and daily routines.

• Sleep Logs or Diaries: Patients are often asked to complete a sleep log for one to two weeks. This tool provides a detailed, day-to-day picture of sleep patterns and habits.

• Meeting Diagnostic Criteria: The clinician confirms that the patient's symptoms meet the formal criteria. For a diagnosis of chronic insomnia, this means:

  1. Difficulty with sleep initiation, maintenance, or early morning awakening.

  2. The sleep problem occurs at least three nights per week.

  3. The problem has persisted for at least three months.

  4. The sleep disturbance causes clinically significant distress or impairment in daily life.

  5. The difficulty occurs despite having adequate opportunity to sleep.

  6. The insomnia is not better explained by another sleep disorder or the effects of a substance.

• Questionnaires: Standardized questionnaires can be used to screen for insomnia and measure its severity, such as the Insomnia Severity Index (ISI) (Morin et al., 2011).

• Objective Testing (When Necessary): Polysomnography, an in-lab sleep study, is not required for a routine insomnia diagnosis. However, it may be used when another primary sleep disorder is suspected, such as obstructive sleep apnea (OSA) or restless legs syndrome (RLS).

If you feel you meet these criteria, then you can assess how serious your symptoms are using our online insomnia test.

Once a diagnosis is made, it's also important to understand the other health issues that can be associated with insomnia. What are these related problems?

What Health Problems Are Linked to Insomnia Disorder?

Persistent insomnia is not merely a problem of tiredness; it is associated with an increased risk for a range of serious physical and mental health conditions.

While insomnia often co-exists with other disorders, numerous studies that follow people over time, known as longitudinal studies, show that a history of insomnia can independently predict the future development of new health problems (Baglioni et al., 2011).

Key health problems linked to insomnia include:

• Mental Health Disorders: There is a strong two-way relationship between insomnia and psychiatric conditions. A history of insomnia significantly increases the risk for the future onset or recurrence of:

  • Depression: Insomnia is a major predictor for developing major depressive disorder, with some studies suggesting a two-fold increase in risk (Baglioni et al., 2011).

  • Anxiety Disorders: Difficulty sleeping is closely linked to a higher risk of developing anxiety disorders in the future.

    Substance Use Disorders: Individuals with insomnia may be at greater risk for issues with alcohol or other substances.

• Suicidal Behavior: Persistent insomnia has been identified as an independent risk factor for suicidal behavior, separate from the risk posed by depression alone.

• Cardiovascular Disease: Chronic insomnia is associated with an increased risk of developing hypertension and having a myocardial infarction, which is a heart attack (Sofi et al., 2014).

• Metabolic Disorders: The strongest evidence for cardiovascular and metabolic complications is found in the type of insomnia where individuals not only feel they sleep poorly but also show objectively short sleep (less than 6 hours) when measured in a lab. This group has a particularly high risk for hypertension (Vgontzas et al., 2012).

The strongest evidence for cardiovascular and metabolic complications of insomnia has been found in individuals with objective short sleep duration (<6 hours) which is less than 50% of insomnia sufferers.

Overall, these associations highlight that insomnia is more than just a sleep problem; it is a significant public health issue with far-reaching consequences.

Given these potential health problems, how does the condition affect a person's day-to-day existence?

How Does Insomnia Disorder Affect Daily Life?

The impact of insomnia disorder extends far beyond the bedroom, affecting nearly every aspect of a person's daily life, from their emotional well-being to their performance at work and their social relationships. The daytime consequences are a required component of the diagnosis and are often what motivate a person to seek help.

Key impacts on daily life include:

• Reduced Quality of Life: Individuals with insomnia consistently report a lower overall quality of life and reduced feelings of well-being (Olfson et al., 2018).

• Impaired Cognitive Functioning: Many people experience difficulties with attention, concentration, and memory, which can interfere with complex tasks and learning.

• Emotional and Mood Disturbances: Irritability and mood disturbances are very common daytime symptoms. This can strain relationships with family, friends, and colleagues.

• Work and Academic Impairment: Insomnia can lead to decreased productivity, being more prone to errors, and increased absenteeism from work. The economic burden of this lost productivity is substantial, estimated to be over $63 billion annually in the U.S. alone (Kessler et al., 2011).

• Interpersonal and Social Problems: The combination of fatigue and irritability can lead to withdrawal from social activities and create tension in relationships.

• Preoccupation with Sleep: Many individuals with chronic insomnia become excessively focused on and worried about their sleep difficulties and the perceived daytime consequences. This preoccupation can itself become a source of stress and perpetuate the cycle of poor sleep.

Given these wide-ranging effects, finding an effective way to manage the condition is very important. So, how is insomnia disorder treated?

Insomnia Treatment: How Do You Treat Insomnia?

Recommended First-Line Treatment

The recommended treatment for chronic insomnia disorder is Cognitive behavioural therapy for insomnia or CBT-i , which is considered the first-line approach by major clinical guidelines (Qaseem et al., 2016; Riemann et al., 2017). While treatments with medication, known as pharmacological treatments, are also used, CBT-I has demonstrated greater success in sustaining improvements over the long term (Morin et al., 2006a).

1. Cognitive-Behavioral Therapy for Insomnia (CBT-I): CBT-I is a structured, skills-based therapy that targets the perpetuating factors—the unhelpful thoughts and behaviors—that prolong insomnia. Scientific studies have shown that around 70-80% of people treated with CBT-I experience a restoration of normal sleep, and around 50% have complete remission. It is not just sleep hygiene; rather, it is a treatment with multiple components that typically includes:

• Stimulus Control Therapy: This technique aims to re-strengthen the association between the bed and sleep. It involves rules such as going to bed only when sleepy, getting out of bed if you're still awake after what feels like 20 minutes, and using the bed only for sleep and intimacy (Bootzin et al., 1991).

• Sleep Restriction Therapy: This therapy limits the amount of time you spend in bed so that it more closely matches the amount of time you are actually sleeping. This process helps to build up your body's natural 'sleep pressure,' a concept known as the homeostatic sleep drive, which in turn makes your sleep deeper and more solid. As your sleep becomes more consistent and you spend less time awake during the night—a measure known as improving sleep efficiency—the amount of time you are allowed in bed is gradually extended (Spielman et al., 1987).

• Cognitive Therapy: This component focuses on identifying, challenging, and changing unhelpful thoughts and beliefs about sleep (e.g., "I must get 8 hours of sleep or I won't be able to function tomorrow").

• Relaxation Training: Techniques like diaphragmatic breathing (deep belly breathing), progressive muscle relaxation, or mindfulness are taught to reduce the physical and mental arousal that interferes with sleep.

• Sleep Hygiene and Education: This provides information about lifestyle practices (e.g., diet, exercise, caffeine intake) and environmental factors (e.g., light, noise) that can affect sleep. While helpful, sleep hygiene alone is not an effective treatment for chronic insomnia.

Medicine For Insomnia: Sleep Medications

Recommended Second-Line Treatment

Pharmacological Treatment (Medication): Medications can be used as a secondary treatment to CBT for insomnia or when CBT-I is not available.

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.

There are several classes of FDA-approved hypnotic drugs, which are medications that induce sleep:

• Benzodiazepine Receptor Agonists (BzRAs): This category includes older benzodiazepines (e.g., temazepam) and newer "Z-drugs" (e.g., zolpidem, eszopiclone). They work by enhancing the effects of GABA, the brain's main calming neurotransmitter.

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)

• Melatonin Receptor Agonists: Ramelteon acts on the body's melatonin receptors to help regulate the sleep-wake cycle.

• Dual Orexin Receptor Antagonists (DORAs): Drugs like suvorexant and lemborexant work by blocking orexin, a chemical in the brain that promotes wakefulness.

• Low-Dose Doxepin: This is an older antidepressant that, at very low doses (3-6 mg), acts as a potent antihistamine to help people stay asleep.

Many other drugs are used "off-label" (meaning for a purpose other than what they were officially approved for) to treat insomnia.

What are some practical ways people can start to manage this condition?

Can Natural Sleep Aids & Supplements Help 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 natural sleep aids have little to no benefit in insomnia treatment.