In general and simply defined, the term insomnia refers to having difficulty with sleep. Insomnia is the most commonly reported sleep-related problem. Insomnia can be defined as a repetitive problem with sleep initiation, maintenance, early morning wakening, or sleep quality despite adequate opportunity (Dyonzak, 2011). Symptoms must last for more than one month and there must be some form of daytime social, health, occupational impairment for a formal diagnosis of a sleep disorder to be made. Poor or inadequate sleep can impact cognitive performance and quality of life. A diagnosis of sleep disorder is usually not made if it is part of a more serious psychiatric or mood disorder.
While nearly half the population has a bad night or two estimates suggest from 10% to 20% of the adult and elderly population may suffer from chronic insomnia (Riley, 2005; Becker, 2006). Rates of insomnia have been found to be somewhat higher for post-menopausal women and the elderly.
Since insomnia may be a primary disorder or may be a product of comorbid medical or psychiatric disorders a comprehensive history and physical examination is vital to determining the underlying cause of the insomnia (Curry et al., 2006). Individuals should seek medical and psychological advice if symptoms persist for longer than one month and they experience any daytime impairment. It is important that early treatment is initiated to prevent psychopathological complications (Dopp & Phillips, n.d.).
Insomnia is often a symptom of a larger medical or psychological disorder. It can also be the result of a more serious drug or alcohol abuse issue. Therefore when diagnosing insomnia, it is crucial for clinicians to obtain a complete medical, psychological, drug and sleep history. A self-completed daily sleep log is often helpful in providing accurate information for the assessment and treatment of sleep disorders.
Sleep disorders may be caused by common substances such as nicotine, caffeine or alcohol. Stimulant medication and illicit substances such as cocaine, amphetamines and others commonly result in sleep disturbance. Depression, anxiety, post-traumatic stress disorder (PTSD), and bipolar disorder are psychiatric disorders which often have sleep disorder as a prominent symptom. Intermittent sleep disturbance can also be a sign of complicated grief.
Acute and chronic medical illnesses and the medications often used to treat them also have potentials to cause insomnia. Steroid medication used to treat inflammation and other conditions is a common culprit as are stimulant medications used to treat ADHD. Individuals with chronic pain often suffer a cycle of muscle pain, muscle tension, anxiety, and sleep difficulties.
While insomnia may be co-morbid with medical and psychiatric conditions, it has also been associated with increased risk of medical and psychiatric disorders (Leger et. al., 2002). In employment settings it has been associated with increased absenteeism and work performance.
A common question is how many hours do we need to generally function well? For most people around 7-8 hours works well. Studies show decreased performance on a number of tasks for most people as hours slip further below this. Another sleep problem can involve sleeping too many hours. People vary, but it is rather unusual to need more than 9 hours sleep. There are some studies which suggest too much sleep can be associated with diabetes, hypertension, increased weight, and other medical problems. A good discussion from the National Sleep Foundation is referenced at the end of this article.
Common Signs and Symptoms of Insomnia
- Inability to fall asleep
- Difficulty returning to sleep
- Awaking too early in the mornings
- Feelings of fatigue the following day
Secondary Signs and Symptoms
- Fatigue (tiredness)
- Lack of concentration
- Lack of focus
- Memory deficits
- Impairment in motor coordination
- Irritability and impaired social interaction
- Fluctuating shifts or work schedules
- Traveling to different time zones (jetlag)
- Drinking caffeine
- Certain prescriptions or non-prescribed medication
Weigh loss Supplements
Some Antidepressants (including bupropion or Wellbutrin®)
Asthma Medications (including albuterol or Ventolin®)
Blood pressure medications (including beta blockers).
- Acute insomnia can generally last anywhere between one night to a few weeks
- Chronic insomnia is generally characterized by an inability to sleep at least three nights during the week for a month or longer.
- Sleep disturbances lasting 1 month or more is clinically significant and should be an indication to seek medical attention.
DSM-IV Criteria for Insomnia Diagnosis
At least one of the following:
- Difficulty initiating or maintaining sleep
- Poor sleep quality
- Trouble sleeping despite adequate opportunity and circumstances for sleep
- Waking up too early
and at least one of the following daytime impairments:
- Memory impairment
- Concerns or worries about sleep
- Daytime sleepiness
- Errors or accidents at work or while driving
- Fatigue or malaise
- Gastrointestinal dysfunction or poor school performance
- Tension headaches
Once medical and psychological evaluations have eliminated the possibility of co-morbidity treatment options for primary or secondary insomnia can be explored. Treatment of insomnia usually starts with behavioral and lifestyle modification for proper sleep hygiene. These are discussed in part II of this guide: our Sleep Hygiene Handout. Maintenance of a sleep diary is also helpful in this process.
Should efforts at maintaining proper sleep hygiene fail despite an adequate trial, more formal therapies and consideration of the risks and benefits of various medications should be reviewed by a physician in the context of an individual’s medical history, risk of addiction, work demands, and other medications which the individual may be taking.
More in this series on the basics of Insomnia:
Part V: Classification of Sleep Disorders
Treatment Options for Insomnia is the subject of Part III of this guide to understanding insomnia.
Becker, P.M. (2006). Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Psychiatric Clinics of North America, 4(2), 168-92.
Curry, D.T., Einstein, R.D., & Walsh, J.K., (2006). Pharmacologic management of insomnia: Past, present, and future. Psychiatric Clinics of North America, 29 (4),871-93.
Dopp, J.M., & Phillips, B. (n.d.). Sleep disorders, (6th Ed.). Pharmacotherapy Self-Assessment Program
Dyonzak., J.V.(2011). Diagnosis and psychological and behavioral treatment of insomnia. Disease-a-month, 57(7), 338-44.
Leger D, Guilleminault, C, Bader G, Levy E, & Paillard M. Medical and socio-professional impact of insomnia. Sleep. 2002; 25:625-629.
Riley, W. T. (2005). Manifestations and management of chronic insomnia: NIH state-of-the-science conference findings and implications.
Should you require help with management and treatment of your sleep problems and reside in the North Central Florida area, please call Clinical Psychology Associates of North Central Florida at (352) 336-2888 for an intake. No referral necessary.