Insomnia

What is Insomnia? | Symptoms | Risk Factors & Causes | Diagnosis | Treatment | FAQ

Insomnia is characterised by difficulties falling or staying asleep, and/or difficulties returning to sleep after early morning awakenings. It is a common condition that can develop into Insomnia Disorder when it becomes associated with significant distress or impairment in daytime functioning, and occurs despite an adequate opportunity for sleep. Marked impairment in function and quality of life, psychiatric and physical morbidity, and accidents are associated with insomnia disorder, leading to serious consequences on an individual’s physical health and wellbeing when not managed properly [1].

Primary insomnia refers to difficulties falling and/or staying asleep that cannot be explained by other existing medical, psychiatric or substance (such as substance abuse or medication) [2].

Secondary insomnia is the most common form of insomnia characterised by difficulties sleeping or staying asleep caused or aggravated by other medical (e.g., back problems, headaches, etc.) or psychiatric conditions (e.g., depression, anxiety, etc.) or substances [3]. One can determine if he/she is experiencing secondary insomnia by checking if the severity of the insomnia follows the course of another disorder. For instance,

• Does the beginning of your sleeplessness follow shortly after the onset of another disorder?
• Does your sleeplessness get better after your primary condition improves?

Insomnia can also be classified based on the duration and frequency of symptoms (DSM-V) [4]:

• Episodic insomnia (or short-term insomnia, according to the International Classification of Sleep Disorders, ICSD-3): when symptoms last at least 1 month but less than 3 months
• Persistent (or chronic insomnia): when symptoms last for at least 3 months
• Recurrent insomnia: repeated episodes of insomnia within a year, each lasting 1-3 month in duration

Some signs of insomnia based on the DSM-V include [5]:

• Difficulties falling asleep and/or staying asleep — constantly waking up at night
• Waking up early and experiencing difficulties returning to sleep
• Fatigue; daytime sleepiness
• Irritability or moodiness
• Difficulties concentrating
• Having poor memory
• Decreased performance at school or work
• Anxiety related to sleep

Risk factors, also known as predisposing factors, increase one’s vulnerability to insomnia. Exposure to precipitating events like major life change or long-term stress cause individuals predisposed to insomnia to develop sleep difficulties. Some risk factors include (DSM-V):

• Genetic and physiological factors
  • insomnia occurs more commonly among those who have a family history of insomnia 
• Environmental factors 
  • unconducive environments for sleeping such as noise, light, uncomfortably high or low temperature, and high altitude
• Temperamental factors 
  • Insomnia occurs more among those who have a tendency to ruminate/have an anxious predisposition 

Causes are also known as precipitating factors that contribute to insomnia. There are many causes of insomnia, but they are difficult to pinpoint with precision given the multitude of factors influencing our body at any given time. Nevertheless, there are still some common causes of insomnia that many experiencing insomnia share:

Primary insomnia is not a cause or symptom of another disorder and does not have obvious identifiable causes, unlike secondary insomnia [6]. 

While the causes remain unclear, primary insomnia is often related to psychological conditioning that interferes with sleep. Initially, most cases of insomnia develop due to external causes. If sleeplessness continues in the long term, this can cause patients to associate sleep with distress and eventually, lead to a vicious cycle — as one tries harder to sleep, the more stress and frustration accumulates which further interferes with sleep. This conditioning outcome can persist even after the initial psychiatric or media stressor has been resolved. It can also be perpetuated as long as thoughts and feelings of apprehension, related to difficulties sleeping, continue in the environment one has been struggling to sleep in. As a result, some individuals may find it easier to fall asleep when outside of their bedrooms or outside of their usual routines as opposed to in their own beds (DSM-V) [7].

Common psychiatric causes of secondary insomnia include [8]:

• Anxiety
• Depression
• Panic disorder
• Adjustment disorders
• Somatoform disorders
• Personality disorders

There are many medical conditions that can cause disturbances to sleep such as but not limited to [9]:

• Asthma
• Pulmonary disease
• Heart disease
• Back problems
• Headaches
• Alzheimer’s disease 
• Seizures

Substances such as prescription and over-the-counter medication, and substance abuse can also interfere with sleep, leading to Secondary Insomnia [10].

Insomnia can also be caused by the following: 

1. Stress and anxiety: Worries and stress resulting from work, school, relationships, health or finances can cause sleep disturbances. Trauma and sudden adverse life events can also result in insomnia. The body’s physical response to stress contributes to hyperarousal, and mental stress can have the same effect [11].
2. Lifestyle factors: Insufficient exercise, or consumption of alcohol and caffeine late in the evening or night contribute to difficulty falling asleep.  Shift work or jet lag results in poor sleep quality as night shift work forces individuals to sleep at times when activities in our natural environment and our own biological rhythms signal us to be awake [12].
3. Age: Researchers have found that people over the age of 60 have less sleep efficiency. They spend less time in deep sleep and Rapid Eye Movement (REM) sleep, which makes it easier for their sleep to be disturbed [13].

Generally, short-term insomnia is more often related to life stresses, acute illnesses, or medications, whereas chronic insomnia is more likely to be related to behavioural factors or the effects of chronic mental or medical disorders [14].

According to the DSM-5, the following criteria are to be met to be diagnosed with Insomnia Disorder [15]:  

1. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
   1. Difficulty falling asleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
   2. Difficulty maintaining sleep, characterised by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
   3. Early-morning awakening with inability to return to sleep.
2. The sleep disturbance causes disruption to daily functioning in the social, occupational, educational, behavioural aspects.
3. Sleep difficulty occurs at least 3 nights per week.
4. The sleep difficulty is present for at least 3 months.
5. Sleep difficulty occurs despite adequate opportunity for sleep.
6. 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, or  parasomnia).
7. Insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
8. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

While insomnia may exist either as an independent condition or a condition comorbid with other disorders, mental health professionals will diagnose individuals with Insomnia Disorder if it causes significant distress and impairments in their daily functioning.

For effective treatment of insomnia in the short-term, mental health professionals commonly prescribe Benzodiazepines. Due to side effects including physical dependence, sedation and impairment of motor abilities, they will not recommend long-term consumption [16]. In addition, the use of medication in general should be carefully considered if a patient currently is undergoing treatment for existing primary conditions [17].

Other medications used to treat insomnia include [18]:

• flurazepam (Dalmane) and quazepam (Doral) which are longer-acting medications that are less likely to result in rebound insomnia, but increases chances of causing daytime sleepiness.
• triazolam (Halcion), temazepam (Restoril) and zolpidem (Ambien) which are shorter-acting medications with effects that discontinue by morning, hence reducing the likelihood of sleepiness during daytime.

​​Melatonin is a popular choice of remedy for insomnia, however its effectiveness remains controversial. Research has shown its effectiveness in addressing insomnia resulting from circadian schedule changes (e.g., jetlag, shift work changes) by quickening our body’s adaptation process, but there is no research supporting its effectiveness for chronic insomnia. We should be careful with the amount of Melatonin we consume as high doses of melatonin can cause side effects including sleep disruption, daytime fatigue, headache, dizziness and increased irritability. Melatonin is also not controlled for in terms of its purity, concentration and absence of harmful impurities, unlike prescription drugs [19], which could potentially pose additional risks to one’s health.

As such, while melatonin may be a quick solution for short term adaptation to jet lag of work shift changes, other safer forms of treatment are still recommended.

Research has illustrated the effectiveness of psychological intervention on alleviating primary insomnia. Some forms of intervention include [20]:

• Cognitive therapy

  It uses techniques to address maladaptive beliefs an individual may hold about sleep.

• Cognitive-behavioural Therapy

  It targets beliefs clients may hold about sleep and behavioural patterns that hinder one from falling and/or staying asleep. 

  • Some behavioural techniques include relaxation methods such as progressive muscular relaxation, imagery techniques and body focusing which can help induce feelings of calm and relaxation, both physically and mentally

• Sleep Restriction Therapy

  It involves restricting time an individual spends in bed to the time he/she generally spends sleeping before gradually increasing the time spent as the individual’s duration of sleep increases. This helps to accumulate a sleep debt in the initial stages which allows the individual to fall asleep more quickly on subsequent nights [21].

• Stimulus Control Therapy

  It comprise a set of instructions to help individuals reassociate bed with sleep by eliminating counterproductive habits that interfere with sleep. The list of instructions include [22] [23]:

1. 1. Try to use your bed only for sleep. This helps your brain associate your bed with rest instead of stimulating activities that are not productive for sleep e.g. watching television or playing games.   
   2. Go to bed only when you are sleepy. If you find yourself being unable to sleep, get out of bed and leave the bedroom. Return to bed when you are sleepy.
   3. If you cannot fall asleep within 15-20 minutes upon returning to bed, repeat step 2 as many times as needed until sleep occurs within 15 to 20 minutes.
   4. Get out of bed at the same time every morning regardless of how much you slept. This helps to establish a consistent sleep cycle.
   5. Do not nap during the day or sleep in locations other than your bed.

Overall, pharmacological treatment is effective in addressing insomnia in the short term, but psychological interventions have more lasting effects [24]. They also better address chronic insomnia which are typically associated with maladaptive cognitions and behaviours that represent major perpetuating factors. These factors must be addressed therapeutically to achieve a successful long-term outcome [25].

Having healthy sleep habits can make it easier for you to fall asleep and stay asleep. This can include [26]:

• Arranging a conducive sleep environment for yourself by setting a comfortable room temperature while minimising artificial light from electronic devices. 
• Having a regular wake and sleep time schedule to prevent sleep disruption.
• Abstaining from consuming caffeine, nicotine, and alcohol close to your bedtime. While alcohol may make it easier to fall asleep, it causes sleep to be lighter as well. Hence, people are more likely to be awakened in the middle of the night. 
• Adopting healthy coping mechanisms to manage stress. You can set a routine that helps you to relax before bedtime such as reading a book, listening to your favourite music, or meditating. 
• Avoid medication that can disrupt sleep if possible.