What to Do About Insomnia

Can't Sleep? Insomnia Types, Causes, and Treatments

From the WebMD Archives

Just can't get to sleep? Can't stay asleep? Waking up too early? Not feeling refreshed and restored in the morning? Not functioning well during the day? You may have insomnia.

Up to about one-third of the population have symptoms of insomnia. Those with insomnia typically experience:

  • Sleepiness
  • Fatigue
  • Poor concentration
  • Decreased alertness and performance
  • Muscle aches
  • Depression during the day and night
  • An over-emotional state (tense, worried, irritable, and depressed)

While it may be very difficult to get to sleep at bedtime, you find yourself "out like a light" in front of the TV, at a movie, reading, or even driving. And anticipating getting a poor night's sleep as well as developing rituals and behaviors you think will help your sleep (going to bed earlier) may actually have the opposite effect -- and make the problem worse. Such is the plight, misery, and danger of insomnia.

Many of us experience temporary insomnia from a few days to a few weeks. This kind of insomnia usually results from normal events in our lives such as:

  • A stressful event
  • Emotional stress
  • Illness
  • Temporary pain
  • Disturbances in sleep hygiene (environmental factors under your control that may contribute to disturbed sleep and insomnia)
  • Disruptions to circadian rhythm (the 24-hour rhythmic regulation of our body processes)

When stressful situations resolve, when you recover from illness, when the pain goes away, when sleep hygiene improves -- then sleep usually improves.

Circadian rhythm disruptions like shift work and jet lag may contribute to insomnia because the times you fall asleep and wake up are temporarily shifted. Proper sleep hygiene, particularly the amount of and timing of light, can help re-set your circadian rhythm and improve the symptoms of insomnia from these causes.

Medical Causes

Insomnia also may result from a variety of medical conditions, pain, and even the treatments for these disorders. And poor sleep hygiene can make these medical conditions worse.

Depressive illnesses are almost always associated with sleep disturbances. Those suffering from anxiety may be unable to sleep due to intrusive thoughts, an inability to relax, obsessive worrying, and an "overactive" mind. Bipolar, panic, and psychiatric disorders are each associated with sleep disturbances as well.

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Pain from arthritis, other rheumatologic diseases, cancer, and various neurological disorders, like neuropathy from diabetes are common causes of insomnia. Gastrointestinal disorders like acid reflux and stomach ulcers, as well as angina from heart disease may cause chest pain, and consequent awakenings during the night. In addition, cluster headaches may be precipitated during certain stages of sleep or occur from lack of sleep.

Treatment for these types of insomnia rests primarily with treating the underlying medical condition. These conditions, as with many others, interact with sleep in a complex manner, with each impacting the other. Exactly how all these factors interact is not completely known, but being aware of the sleep component allows us to target each aspect individually and achieve vastly improved interventions and treatments. So it is critical to understand and communicate to your doctor how your condition affects your sleep and that your sleep disturbances may exacerbate your medical condition. This will ensure that he/she may integrate your sleep problem into the overall treatment plan, and utilize a sleep specialist, if needed.

The "pins and needles," "internal itch," or "creeping, crawling sensation" of restless leg syndrome (RLS) also make it quite difficult to fall asleep, especially since those symptoms occur more often when one is sleepy or lying down and are relieved only by vigorously moving the legs. The symptoms of RLS may awaken one out of sleep, forcing the sufferer to walk around to relieve the discomfort.

Most people with RLS also have periodic limb movement disorder (PLMD), repetitive movements of the toe, foot, and sometimes knee and hip during sleep. These movements may cause arousals that lead to non-restorative sleep. Your doctor can prescribe various medications to reduce or eliminate the movements and the associated sleep disturbances (arousals) caused by these disorders. This results in a more sound sleep, one from which you awaken restored and refreshed.

Other illnesses that often have nighttime symptoms that cause awakenings include:

Another reason why communicating symptoms of insomnia to your doctor is so important is the possibility that the treatments for medical conditions themselves may cause or worsen insomnia. Following is a brief list of some classes of drugs that may fall into this category:

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Back to Sleep

Developing good sleep hygiene is very important for insomnia relief. For example, smoking, drinking, and exercise can affect your sleep dramatically. What you actually do in bed (like reading or watching TV), the temperature of room, noise levels, the timing and amount of fluids you drink, and the food you eat significantly impact insomnia. Exposure to light in the evening (looking at a bright computer screen, turning on the light to go to the bathroom) may alter your circadian rhythms. Poor hygiene alone can generate significant sleep problems.

Treatment for insomnia falls into two basic categories, medication and behavioral strategies for sleep initiation. Doctors tend to use one of three different types of medication for insomnia, including:

  1. The so-called non-benzodiazepine or "non-valium-like" hypnotics (such as Ambien and Sonata) are designed for insomnia and are often first-line treatment. They are especially effective because they work quickly, do not disrupt your "sleep architecture" or the quality of your sleep.
  2. When considering underlying depression associated with insomnia, antidepressants are often used because of their sedating side effects.
  3. Hypnotics (including Restoril, Halcion, and Klonopin) should be used only in selected patients because they are potent medications that greatly impact the quality of sleep and may have severe side effects, including daytime drowsiness and addiction.

Behavioral strategies include:

  1. Sleep restriction, that is, restricting where one sleeps to only the bed. The idea here is that you sleep only in bed and you stay in bed only when asleep. Do not lie awake in bed for hours on end. If you do not fall asleep after about 25 minutes, get out of bed and do something calming, like read a book. This helps reduce the anxiety-provoking association of being awake while in bed, and ultimately may create the positive association of sleeping well in bed. When restricting sleep in this manner, you will eventually become so tired that you become sleepy earlier in the evening, relieving insomnia. Given how tired one will be when beginning this regimen, activities where safety is an issue, like driving, should be avoided.
  2. Stimulus control involves making the bedroom a place for sleep and sex only -- no TV-watching, for example. This again tries to create associations to help train your mind.
  3. Relaxation uses certain techniques to relax your mind and body, making it easier to fall asleep and stay asleep.
  4. Cognitive behavioral therapy. Here a psychologist helps to eliminate those thoughts associated with a poor night's sleep.

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All the therapies noted above should be instituted, directed, and monitored by a doctor after a proper evaluation and diagnosis.

As if the misery of insomnia is not enough, chronic insomnia takes an additional toll. Studies show an increased mortality risk for those reporting less than either six or seven hours per night. One study found that reduced sleep time is a greater mortality risk than smoking, high blood pressure, and heart disease.

So, if you have symptoms of insomnia, it is very important take it as seriously as any other medical condition or illness. Establish good sleep hygiene and see your doctor or sleep specialist.

WebMD Feature Reviewed by Stuart J. Meyers, MD on September 01, 2004

Sources

SOURCE: Sleep Medicine, Kryger, Meir, et al., Third Edition, 2000. WebMD Medical Reference from Healthwise: "Insomnia."

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