Insomnia

Globally, around one-third of people experience unsatisfying sleep¹. If sleeping difficulties meet certain criteria, they are diagnosed as the sleep disorder insomnia².

Since insomnia can reduce cognitive ability, decrease quality of life, and potentially lead to other health issues, treatment is important. We explore what insomnia is and the disorder’s various subtypes, symptoms, causes, and treatments.

What Is Insomnia?

According to the American Academy of Sleep Medicine, insomnia is defined as difficulty either falling or staying asleep that is accompanied by daytime impairments related to those sleep troubles.

Insomnia in Children and Teens

People of any age may experience insomnia. That said, infants less than 6 months old are rarely diagnosed with insomnia since it is common for them to not sleep through the night.

When diagnosing insomnia in children and teens, doctors may look for slightly different symptoms than when diagnosing adults. For example, they may ask if the child resists their bedtime or requires a parent’s help to go to sleep. Doctors may also ask if children and teens with sleep difficulties have academic or behavioral problems.

In some cases, a child’s sleep troubles result from an attachment to certain items or settings needed to fall asleep. For example, a child may become reliant on being rocked or having a special toy with them in order to fall asleep, preventing them from sleeping well in any other setting.

Types of Insomnia

The American Academy of Sleep Medicine categorizes insomnia into different types: chronic insomnia disorder, short-term insomnia disorder, and other insomnia disorder.

Chronic Insomnia Disorder

Chronic insomnia is when a person experiences sleeping difficulties and related daytime symptoms, like fatigue and attention issues, at least three days per week for more than three months or repeatedly over years. It is estimated that about 10% of people have chronic insomnia disorder.

People with chronic insomnia commonly feel distressed about their inability to sleep and the daytime symptoms caused by those sleep issues. Symptoms are generally severe enough to affect a person’s work or school performance as well as their social or family life.

Short-Term Insomnia Disorder

Short-term insomnia disorder involves the same sleep difficulties and symptoms as chronic insomnia disorder, but those problems are experienced for less than three months and may not occur three times per week. It is believed that between 15% and 20% of adults experience short-term insomnia in any given year.

Often, short-term insomnia can be traced to an external cause, such as a life stressor like divorce, the death of a loved one, or a major illness. People who tend to be light sleepers are more likely to experience short-term insomnia than others.

If short-term insomnia disorder persists over multiple months, it can become reclassified as chronic insomnia disorder.

Other Insomnia Disorder

In specific cases, a doctor may diagnose a condition called other insomnia disorder if a person has significant sleeping problems but does not meet all of the criteria for either chronic or short-term insomnia disorder. Because of its vague nature, this diagnosis is rarely used.

Primary and Secondary Insomnia

Primary and secondary insomnia are no longer official, diagnosable conditions. Although these were previously recognized by the American Academy of Sleep Medicine (AASM) as distinct types of insomnia, they were removed from the current International Classification of Sleep Disorders – Third Edition (ICSD-3), which was published in 2014.

In the past, primary insomnia was thought to arise on its own, while secondary insomnia was viewed as resulting from another disorder. The AASM switched the diagnostic categories to chronic insomnia disorder, short-term insomnia disorder, and other insomnia disorder because these more closely reflect what has been found in relevant research studies and clinical medical practice.

The American Psychiatric Association (APA) has also changed its classification. While the APA’s Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) listed primary insomnia as a diagnosable disorder, this was revised to be called insomnia disorder in the DSM-5³, which was published in 2013.

Other Types of Insomnia

The current sleep disorder classification system does not include any types of insomnia besides chronic insomnia disorder, short-term insomnia disorder, and other insomnia disorder. However, doctors and researchers may mention names that were previously used to describe subtypes of insomnia.

• Paradoxical insomnia: Also referred to as sleep state misperception, paradoxical insomnia occurs when a person feels their sleep is greatly disturbed but no other evidence confirms the presence of sleep difficulties. People with paradoxical insomnia may greatly underestimate how much sleep they actually get.
• Sleep-onset insomnia: Both chronic and short-term insomnia can involve trouble falling asleep when first lying down for the night, which may be referred to as sleep-onset insomnia.
• Sleep-maintenance insomnia: Difficulty staying asleep throughout the night may be called sleep-maintenance insomnia, and this can also affect people with either chronic or short-term insomnia. Middle-aged and older adults with insomnia are more likely to experience issues with maintaining sleep throughout the night than with falling asleep.
• Behavioral insomnia of childhood: In the past, a child’s inability to sleep without specific items or routines was called behavioral insomnia of childhood. For example, a child unable to sleep without a favorite stuffed animal might have been described as having this variant of insomnia.
• Fatal insomnia: Although it contains the word insomnia in its name, fatal insomnia is not a sleep disorder. Rather, fatal insomnia, also called fatal familial insomnia (FFI), is a very rare genetic disorder that causes progressive brain damage. Fatal familial insomnia is a neurological disorder that involves many symptoms, including increasingly severe sleep difficulties.

Insomnia vs. Occasional Sleeplessness

Up to 35% of people occasionally experience insomnia-like symptoms, such as trouble falling or staying asleep. These bouts of sleeplessness do not necessarily mean that a person has insomnia, which is a formally defined sleep disorder.

Sleep difficulties are only categorized as insomnia when they cause a person distress and begin to negatively affect aspects of their life, like work or relationships. To be classified as chronic insomnia, the symptoms must persist for at least three months.

Symptoms of Insomnia

Both short-term and chronic insomnia share certain symptoms. One aspect of those symptoms relates to nighttime sleep, when a a person must experience at least one of these types of sleep issues:

• Trouble falling asleep
• Trouble staying asleep throughout the night
• Unwanted early morning waking
• Resisting sleeping at one’s bedtime (for children and teens)
• Difficulty sleeping without a caregiver’s help (for children and teens)

In addition, a person must have at least one of several daytime symptoms related to their sleeping problems:

• Fatigue
• Impaired attention or memory
• Trouble with work, school, or social performance
• Irritability or disturbed mood
• Sleepiness
• Behavioral issues, like hyperactivity or aggressiveness
• Decreased motivation
• Increased accidents or mistakes
• Worries about or discontent with one’s sleep

For a formal diagnosis of insomnia, these symptoms cannot be a result of another sleep disorder, a lack of opportunity to sleep, or a disruptive sleep environment.

In chronic insomnia, symptoms must occur at least three times per week for at least three months. In short-term insomnia, symptoms may occur less often and be present for less than three months.

The diagnostic criteria for insomnia do not explicitly define what it means to have difficulty falling or staying asleep. However, general guidelines suggest that insomnia may be present if an adult takes longer than 30 minutes to fall asleep or is awake for 30 minutes or more during the night. An approximately 20-minute cutoff is typically used to assess sleeping problems in children.

When to Talk to Your Doctor

Talk with your doctor if you are having difficulty falling asleep or staying asleep. You should also talk with a doctor if you have significant sleepiness or other daytime impairments.

A doctor can ask questions to better understand your situation and order tests to determine if an insomnia diagnosis is appropriate. Symptoms of insomnia can overlap with symptoms of other sleep disorders, so it is important to work with a doctor rather than try to self-diagnose any sleeping problem.

How Is Insomnia Diagnosed?

Doctors generally diagnose insomnia by asking questions about a person’s sleep habits and medical history⁴. They may administer specific questionnaires to assess fatigue, sleepiness, and other symptoms. Sometimes they will request a person keep a sleep diary⁵ for a short period of time. If other sleep disorders need to be ruled out, other assessments, such as a sleep study, may be ordered.

What Causes Insomnia?

There is no single established cause of insomnia. However, research suggests that in many people insomnia likely results from certain types of physiological arousal at unwanted times, disrupting normal patterns of sleep. Examples of such arousal can include a heightened heart rate, a higher body temperature, and increased levels of specific hormones, like cortisol.

Insomnia disorders often occur alongside mental health disorders. It is believed that the cause of insomnia may be distinct in people who have both insomnia and mental health conditions.

Risk Factors for Insomnia

While there is no single cause of insomnia, studies have identified factors that can put a person at a greater risk for experiencing insomnia:

• Being a woman or assigned female at birth
• Older age
• Lower socioeconomic status
• History of being a light sleeper
• History of sleep difficulty while under stress
• Recent life stressors, such as job loss, divorce, or death of a loved one
• Tendency to feel overly concerned about one’s health
• Mood disorders including depression
• Anxiety disorders
• Certain medical issues, like restless legs syndrome or gastroesophageal reflux disease (GERD)
• Overuse of alcohol
• Excessive use of caffeine or other stimulants
• Unstable home conditions or domestic abuse
• Childhood developmental issues
• Having an immediate family member with insomnia
• Lacking a consistent sleep schedule (for children)

It is important to note that not everyone who has one or more of these risk factors will have insomnia, and not everyone with insomnia will have one of these risk factors.

Treatments for Insomnia

Multiple treatments for insomnia disorders are available.

• Education: In the case of short-term insomnia, medical professionals often provide information about insomnia⁶ and explain steps to take if symptoms do not subside. They may also discuss any stressors that may have triggered short-term insomnia.
• Cognitive behavioral therapy for insomnia (CBT-I): Experts in both the U.S. and Europe consider cognitive behavioral therapy for insomnia to be the preferred initial treatment for chronic insomnia disorder. CBT-I helps people manage anxiety they feel about their sleep issues and establish better sleep habits.
• Sleep medications: When a person experiences significant symptoms from insomnia, medication may be recommended. Medication may promote sleep, reduce anxiety about sleep problems, and decrease daytime impairment.

Insomnia Complications

In people with short-term insomnia, a potential complication is the development of chronic insomnia. Sometimes, people with insomnia enter into a difficult-to-break cycle in which their sleep issues exacerbate anxiety about sleep, which then worsens their sleep.

Chronic insomnia can also pose broader risks to health and wellness. If insomnia persists, it can make accidents and injury more likely⁷ and heighten the risk of health problems like high blood pressure and depression.

Tips for Preventing Insomnia

Anyone with symptoms of insomnia should see a doctor to get tailored advice about how to improve their sleep.

In addition, the following sleep hygiene strategies can be used to promote healthy sleep.

• Maintaining the same bedtime and wake time every day, even on weekends
• Reserving use of the bed for only sex and sleep
• Getting out of bed if falling asleep is taking too long or causing anxiety
• Not consuming caffeine, alcohol, or nicotine, especially near bedtime
• Keeping the bedroom both dark and quiet
• Refraining from watching television before bed
• Not checking the clock to see how long it is taking to fall asleep
• Avoiding eating large meals too close to bedtime

For parents of children with sleeping problems, establishing firm, consistent limits around bedtime activities can help prevent a child from becoming dependent on any item or routine to fall asleep.

COVID-19 and Insomnia

Research shows that insomnia rates increased in the early months of the COVID-19 pandemic, with as many as 60% of people⁸ experiencing insomnia symptoms. Some research has found a connection between these insomnia symptoms and worrying about COVID-19.

In addition to pandemic worrying, studies suggest that contracting COVID-19 increases insomnia symptoms. A study of people admitted to a hospital’s intensive care unit found that sleep quality decreased⁹ after a COVID-19 infection, and sleep was still impacted 30 days later.

Anyone who has experienced sleep changes during the pandemic, including from a COVID-19 infection, should consult with a doctor to try to address sleep issues quickly in order to avoid long-term sleep problems.