Insomnia is difficulty getting enough sleep or trouble sleeping without interruption. You may have difficulty falling asleep, may wake up too early, or may wake up periodically during the night. Insomnia of any kind can keep you from feeling rested and refreshed during the day. Almost all of us have episodes of insomnia at some time, but insomnia is not a short-term problem for everyone. Insomnia is classified as chronic when it happens almost every night for at least one month. Insomnia can be related to a medical or psychiatric illness, can be caused by mental stress or excitement, or can be caused by your daytime and bedtime habits.

Your habits and surroundings are the usual causes of short-term insomnia problems. Factors that contribute to insomnia can include:

• Stress or anxiety
• A change in sleeping environment (being a guest at a hotel or a relative's home)
• An uncomfortable sleeping environment (too hot, too cold, too bright, too noisy)
• An uncomfortable mattress
• Pajamas that are too tight
• Having a bed partner who snores or has disruptive sleep patterns
• Watching television, reading a book or problem-solving in your bed, so your brain associates lying down in bed without activities other than sleeping
• Eating a heavy meal before bedtime
• Taking a prescription medication that has insomnia as a side effect
• Drinking alcoholic beverages before bedtime
• Having a high intake of beverages containing caffeine (coffee, tea, cola) during the day
• Cigarette smoking
• Exercising immediately before bedtime
• Not exercising enough during the day, so you have energy to spare
• Taking a hot bath or shower before bed
• Traveling to a different time zone
• Traveling to a much higher altitude
• Shift work

Pregnant women are particularly vulnerable to insomnia. Women who are pregnant may have insomnia because of hormone changes, heartburn, leg cramps or a need to urinate more frequently. In addition, the unborn baby's increasing size often makes it harder for the mother to find a comfortable sleeping position.

Chronic insomnia may be caused by a medical or psychiatric problem. Some common causes of chronic insomnia include:

• Psychiatric illness, especially depression or post-traumatic stress disorder (PTSD)
• Chronic medical illnesses, especially kidney disease, heart failure or asthma
• Painful illnesses, especially arthritis, neuropathy, acid reflux or cancer
• Hormone imbalance, especially menopause or hyperthyroidism
• Taking a prescription medicine that has insomnia as a side effect
• Obstructive sleep apnea – Snorers or people who are overweight may have repeated episodes in which breathing stops for 10 seconds to 30 seconds during sleep, just when the person is relaxing into deep sleep. Sleep apnea is caused most often by relaxing the tongue and throat tissues, which can settle into a position that closes your airway. Your body reacts to sleep apnea by releasing adrenaline-like "alarm" hormones so you will awaken and resume breathing. These hormones keep you awake for periods of the night, and can cause high blood pressure that lasts through the day.
• Narcolepsy – In this condition, the patient's sleep is disturbed at night, but he or she falls asleep suddenly and involuntarily during the daytime
• Restless legs syndrome – This disorder causes uncomfortable sensations in the legs. Symptoms can include twitching of the legs, a habit of repetitive leg movements, and leg cramps.

An estimated 25% to 33% of people in the United States have some form of insomnia. Sleeping pills are usually not the best way to correct an insomnia problem, but they are among the most prescribed medicines in the United States. Women are affected more often than men, especially women older than age 60.

Symptoms of insomnia can include:

• Difficulty falling asleep
• Waking up periodically during the night
• Waking up in the early morning, but not feeling rested
• Feeling tired and irritable during the day
• Having trouble concentrating

Your doctor often can determine the cause of your insomnia by asking about your habits and sleep environment, by reviewing your symptoms, and by examining you. Your doctor may suggest that you keep a sleep diary (a log of your sleep patterns) to provide an exact record of how many hours you sleep, whether symptoms may be your trigger for awakenings, and at what times you wake up. If your doctor suspects that a medical illness is causing your insomnia, you may need additional tests. In some patients, an overnight sleep study at a sleep clinic may be necessary. During a sleep study, your brain waves, breathing pattern and oxygen levels can be monitored, and your body movements can be observed.

Insomnia may last only one or two nights, or it may continue for weeks, months or years. How long insomnia lasts depends on its cause, and on the success of lifestyle changes and treatment.

It helps to have habits that promote healthy sleep:

• Follow a regular sleep schedule. Have a routine bedtime and wake up at roughly the same hour each morning.
• Sleep in loose, comfortable clothes in a comfortable bed.
• Eliminate any sources of noise or bright lights that prevent or disrupt sleep. If noise from outside your bedroom can't be eliminated, it might help if you drown out that noise by creating a monotonous noise of your own. Use a fan, a channel with static noise on your radio, or a recording of ocean waves to make a noise that can lull you to sleep.
• Maintain a comfortable temperature in your bedroom
• Cut down on beverages containing caffeine during the day, since the stimulating effects of caffeine can last for many hours
• Avoid heavy meals before bedtime
• Eliminate alcohol, since many people experience wakefulness as the effect of the alcohol wears off
• Exercise daily, preferably early in the day
• If you read before bed, do this in a chair or in another room
• Consider sleeping in a separate bed or separate room if your partner keeps you awake

If you have chronic insomnia because of chronic pain, medical illness or psychiatric problems, seek prompt treatment for your health problem. Don't assume that insomnia is an unavoidable part of your illness.

Changes in your bedtime surroundings and habits that can promote sleep are usually the most important way to manage insomnia.

Behavioral therapies also may be used to treat some patients with insomnia. These therapies include:

• Relaxation therapy – Special techniques to quiet the mind and relax the muscles



• Sleep restriction – A program that at first permits only a few hours of sleep per night, then gradually increases the nightly sleeping time



• Reconditioning – A program that teaches the patient to associate the bed only with sleeping (and sexual activity) by having the patient go to bed only when sleepy and avoid daytime naps

If you are found to have a medical problem, a mental health problem or a sleep disorder (such as sleep apnea), then specific treatment is important. Medications are available to treat narcolepsy and restless legs syndrome. Special masks can be used to help patients with sleep apnea breathe better.

Your doctor may prescribe medication for short term or occasional use. Today there are a wide variety of medications to choose from. Some act quickly and are most helpful if you have trouble falling asleep. Others have a longer duration of action when the problem is staying asleep. Many of the medications are available as generics, which tend to be much less expensive. Older people should avoid the longer acting drugs because the sedation can last much longer than eight or nine hours.

Melatonin, a dietary supplement, works for some people and not others. It has a good safety profile when used in the doses directed on the label.

Call your doctor if you are worried about sleeping problems, especially if insufficient sleep or disturbed sleep is interfering with your ability to function normally during the day. Insomnia is an urgent medical problem if sleep problems are making it unsafe for you to drive a car or to perform potentially dangerous tasks at work.

In many people with insomnia, normal sleep patterns return within a few days, especially if a lifestyle issue (stress, a habit of heavy meals before bed, a change in time zones) disappears or is modified.

In people with chronic insomnia, the outlook depends on the underlying problem. In people with obstructive sleep apnea, 80% experience relief when they use a nighttime nose mask that provides modest continuous air pressure through the mouth and nose. This mask must be prescribed by a doctor.

National Center on Sleep Disorders Research
National Institutes of Health
6705 Rockledge Drive
One Rockledge Centre, Suite 6022
Bethesda, MD 20892-7993
Phone: 301-435-0199
Fax: 301-480-3451
E-Mail: ncsdr@nih.gov
http://www.nhlbi.nih.gov/about/ncsdr/