What is Insomnia?

Insomnia is most commonly defined as experiencing difficulty sleeping. The condition encompasses a range of various signs and symptoms. In the medical world, insomnia sleep disorder is more commonly associated with evidence of disturbed sleep via polysomnography, a diagnostic test determining sleep quality to help identify sleep disorders. Disturbed sleep usually means:

Difficulty falling asleep or delay in falling asleep.
Difficulty staying asleep or frequent waking through the night.
Nonrestorative sleep, where sleep isn’t restful or rejuvenating.

People who experience sleep arousal can be considered to have insomnia as well. Sleep arousal is a state of partial wakefulness from deep sleep. Insomnia significantly impacts one’s life, making it difficult to carry out basic tasks. It often leaves patients feeling disoriented and tired the day following a sleepless or disturbed night.

What is a Healthy Level of Sleep?

People require different amounts of sleep. Moreover, not everyone has similar sleeping habits. Some people function better in the early mornings whereas others find comfort in late nights. Broadly speaking, sleep can be considered good if one doesn’t take too long to fall asleep, doesn’t wake up once asleep, and wakes up feeling refreshed. How much sleep one requires also depends on age and sex. Toddlers require a lot more sleep than adults, and women need more sleep than men under normal circumstances.

Though some people, often called “early birds”, prefer falling asleep and waking up early, they are not immune to insomnia. Similarly, people who like going to bed late and waking up later in the day aren’t prone to insomnia. Some people are short-sleepers, meaning they get less than recommended sleep, but still feel refreshed and energised during the day. Again, short-sleepers aren’t considered to be insomniacs just because they don’t sleep the recommended hours as per their age and sex. People might sleep varying amounts with different sleeping habits for various reasons. For example, someone working in a volatile environment that requires their attention might, over time, learn how to sleep more lightly than someone who isn’t. Adults are recommended to get between seven to eight hours of sleep. However, just because someone doesn’t sleep the recommended number of hours by “experts”, doesn’t necessarily mean they have insomnia. There is also a growing understanding that the hours of recommended sleep may not be sacrosanct.

Insomnia Types

Though most features of insomnia remain the same across various types, insomnia is usually categorised as follows:

Transient insomnia: When someone suffers from the condition for less than a month
Short-term insomnia: Also known as acute insomnia, this occurs when someone suffers from the condition between one and six months
Chronic insomnia: When someone suffers from insomnia for over six months

Though not duration determined, there are two other types of insomnia:

Primary insomnia: Insomnia that exists on its own, without another medical condition
Comorbid insomnia: Insomnia that exists alongside other disorders, often influencing their treatments or management

Prevalence of Insomnia in India

A study suggests that an estimated 25.7% of the Indian population suffers from insomnia. Given so many people are afflicted by the condition, it’s crucial to treat it correctly.

Insomnia Symptoms and Effects

Sleep is a crucial biological function that influences many aspects of health. Lack of sufficient sleep can exacerbate other conditions like obesity, cardiovascular disease, hypertension, diabetes, anxiety, and more. While insomnia threatens overall health, it has some characteristic symptoms that most people suffering from insomnia share. Insomnia symptoms include:

Lying awake in bed for extended periods before falling asleep
Sleeping significantly fewer hours than recommended
Not feeling well-rested or refreshed after waking up
Staying awake for the majority of the night
Waking up early

The effects of insomnia also vary between short-term and long-term. Sleep is vital to most other major physiological processes. The adverse effects of insomnia can affect people with no underlying conditions as well as worsen the symptoms of a condition someone might be suffering from. Short-term effects of insomnia include:

Heightened stress response
Increased pain perception
Depression
Anxiety
Decreased cognitive function
Decreased memory retention
Performance deficits
Irritability

Long-term effects of insomnia include:

Hypertension
Weight gain
Gastrointestinal disorders
Dyslipidemia
Metabolic syndrome
Cardiovascular diseases
Type 2 diabetes
Cancer

Insomnia also has a profound effect on how you feel the day after a night of poor sleep. Research suggests that insomnia can lead to various daytime effects, including increased drowsiness and daytime sleepiness. Additionally, some people with insomnia report that they have trouble concentrating or recounting some memories the next day. Given insomnia might negatively impact mood, work and social activities might suffer due to the condition as well. Insomnia is commonly associated with performance impairment too. A study shows people with insomnia have trouble with episodic memory, problem-solving, and retention in working memory. This means someone with insomnia might find it difficult to execute tasks they’re otherwise used to when well-rested.

Insomnia Causes

Though the exact causes and pathophysiology of insomnia are still unknown, there are a few things that are thought to contribute to the condition. Treating, managing and preventing insomnia effectively requires a deeper understanding of what might be causing or contributing to insomnia. While more research is still needed, here is a list of causes and contributors to insomnia:

Hyperarousal: Insomnia is closely related to cognitive and somatic activation. Hyperarousal is also associated with emotional processes.
Genetics: People with a family history of insomnia are more prone to the condition. It is thought that gene variants like Apoε4 or HLA DQB1*0602 contribute to the pathophysiology of insomnia.
Molecular mechanisms: It is understood that certain molecules like melatonin promote sleep while others suppress sleep, contributing to insomnia. Further research is needed on the latter.
Sleep-wake regulation: There is a chance that dysregulation in the sleep and waking brain networks leads to the development of insomnia.
Cognitive and behavioural contributors: Certain beliefs and behaviours are thought to worsen or contribute to insomnia. For example, some believe that extended time in bed will help manage symptoms of insomnia when in reality it leads to increased wakefulness. Additionally, it is believed that people prone to excessive worry, stress and intrusive thoughts are more likely to suffer from insomnia.
Additional stimuli: People surrounded by lighter, warmer, or noisier environments are likely to have higher sleep latency.

In addition to these, other factors contributing to insomnia include:

Poor sleeping habits: Irregular sleep patterns and schedules meddle with one’s circadian rhythm. Circadian rhythm refers to the body’s internal clock following day and night patterns. Jet lag and night work shifts are known to interfere with sleeping schedules, possibly contributing to insomnia.
Unhealthy lifestyles: What one eats, drinks, consumes and does throughout the day weighs heavily on insomnia. Stimulants like caffeine, alcohol and tobacco contribute to insomnia in some people whereas habits like daytime naps, screentime into the late evening and poor bedtime routines might contribute to insomnia in others.
Medications: Insomnia might result as a side effect of many common over-the-counter medications. Common culprits include blood pressure medication, anti-asthmatic agents, and antidepressants.
Comorbidity: Various other conditions might lead to insomnia. Conditions like restless leg syndrome, neurological disorders (dementia or Alzheimer’s for example), sleep apnea, and chronic pain often contribute to the development of insomnia.
Pregnancy: Pregnancy is often accompanied by discomfort, disrupted breathing, nausea, reflux and increased urination. To add to this, pregnant women are more prone to restless leg syndrome. These various factors put pregnant women at higher risk of insomnia as well.

What are the Risk Factors for Insomnia?

Certain environments and circumstances put one at risk of insomnia. Some can be changed or worked on while others cannot. Below are the principal risk factors for insomnia:

Age: People are at higher risk of insomnia as they age.
Sex: Women suffer from insomnia more than men. An estimated 41% of women in India suffer from insomnia as compared to men at 32%.
Stress: Stress or worry about sleep leads to a vicious cycle of sleepless nights. Fear or anxiety about daily life in general can lead to insomnia.
Social factors: The environments in which one spends time puts one at greater risk of insomnia. Whether one feels safe at home or in one’s neighbourhood, exposure to nighttime lights and socioeconomic stressors puts one at higher risk of insomnia.

What are the Clinical Complications of Insomnia?

While some of the long-term and short-term effects of insomnia have been discussed in this article, sleep deprivation can have a profoundly negative impact on health. The body does a lot of its healing while asleep, both mentally and physically. People suffering from insomnia have reported a significant drop in quality of life across all dimensions. The complications of insomnia include:

Daytime consequences: Increased risk of accidents while on the job, operating machinery or in public poses the greatest risk to insomniacs. Additionally, people with insomnia typically show signs of lower concentration at the workplace, absenteeism and inability to perform, consequently leading to a decrease in overall work productivity and job performance as well.
Psychiatric disorders: Insomnia is linked to a higher risk of psychiatric disorders than any other condition. Depression and anxiety are common consequences of insomnia. Additionally, insomnia might lead to mood disorders.
Chronic conditions: Insomnia puts people at higher risk of obesity, impaired glucose tolerance, diabetes, cardiovascular morbidity, and more.

How does Insomnia get Diagnosed?

Consult a sleep medicine specialist to identify and diagnose insomnia correctly. A doctor might use an amalgamation of methods including tests, questionnaires, a physical exam and an evaluation of your medical history. One might be diagnosed with insomnia if one has difficulty falling asleep or staying asleep for three or more days in a week. Diagnostic methods include:

Sleep history: By studying patterns of sleep unique to each individual, a doctor can evaluate whether or not one has insomnia based on how long one sleeps each night, how well one sleeps and whether one snores or breathes heavily once asleep. Sleep history might be determined by interviewing your partner or roommate or with a sleep journal. Sleep journals also help highlight any other underlying conditions one might have. A doctor might even give you a questionnaire to understand your sleep history better.
Sleep studies: To ascertain whether you have sleep disorders or not, a doctor might ask you to spend a night in a special sleep centre to study your sleep patterns more closely. This helps determine if one’s insomnia is linked to heavy breathing or movements. Further, a doctor might recommend sleep studies if other treatment methods haven’t worked.
Physical exam: Doctors might listen to your heart or lungs for sleep apnea to rule out other conditions that could lead to sleep problems.

Diagnostic Tests for Insomnia

In certain cases, doctors might require doing tests to identify the condition correctly. While there isn’t any one test that helps diagnose insomnia, there are a range of tests that help eliminate other conditions that might share common symptoms with insomnia. These tests include:

Polysomnography: A test to study real-time bodily signals during sleep. This is often done during sleep studies. While it doesn’t detect insomnia, it helps rule out other sleep disorders.
Actigraphy: Wristwatch-like, this device helps monitor sleep and activity over time. This helps give doctors a reliable picture of one’s sleep patterns.
Blood tests: A doctor might suggest blood tests to rule out thyroid issues or other undetected conditions which impact sleep.

A doctor may recommend other tests to ensure the diagnosis is correct. If one is diagnosed with insomnia, there are a range of treatment options available. A doctor can help decide which is best suited to your medical needs.

How can I Treat Insomnia?

Once insomnia is diagnosed correctly, there are various treatment options available. While it is generally accepted that behavioural therapy should be used as first-line treatment, one might also be prescribed over-the-counter medication to tackle sleeplessness or disturbed sleep. Developing healthier sleep habits might combat insomnia and give you symptomatic relief. Treating symptoms of insomnia requires a multi-disciplinary approach in some instances. Here are the various ways one might treat insomnia:

Healthier Sleep Habits:

Create a sleep-inducing environment: Keep your room cool, dark and quiet with as little exposure to screens from electronics as possible.
Wake up and go to sleep consistently: Ensure you go to sleep and wake up more or less at the same time every day, keeping your schedule in mind.
Avoid stimulants: Substances like caffeine, nicotine, and alcohol might keep you from falling asleep or achieving deep, restful sleep.
Manage your mental health: Stress and anxiety might affect your ability to fall or stay asleep. Find something relaxing you can add to your bedtime routine, like a hot bath before bed, to clear your mind.
Stay fit: Exercise regularly, five to six hours before bedtime as exercise closer to when you sleep might make it harder to fall asleep.
Monitor what you eat and drink: Avoid indulging in midnight munchies or late dinners. If you are someone who wakes up to use the bathroom, avoid drinking too much water closer to bedtime.
Avoid napping: Daytime naps tend to throw off how sleepy you get at night. Avoid afternoon naps to sleep longer through the night.

Cognitive behavioural therapy for insomnia (CBT-I):

CBT-I involves an expert healthcare practitioner identifying and helping change thoughts, feelings and beliefs that are contributing to one’s insomnia. This treatment plan takes over six to eight weeks and is usually the first thing a doctor will suggest when attempting to treat insomnia. It involves cognitive, behavioural and psychoeducational interventions to help one change one’s relationship with sleep. It involves:

Cognitive therapy to calm your nerves
Relaxation therapy or meditation to help you relax before bed
Sleep education for better, healthier sleep habits
Stimulus control therapy to help you maintain a regular sleep-wake cycle

Prescription medicines:

While this isn’t a complete list of medications, it’s extremely important to talk to a doctor before consuming any of the following medicines. Some are for long-term use while others are for short-term consumption. The legality of prescription medication might vary from country to country as well. Here are some prescription drugs used to treat insomnia:

Benzodiazepine receptors agonists: includes medicines such as Zolpidem and Eszopiclone. These medicines promote muscle relaxation and sedation but come with side effects like anxiety, allergic reactions and motor activity while asleep like walking.
Melatonin receptor agonists: includes medicines like Ramelteon. These medicines promote melatonin production, helping one drift into sleep more easily. The side effects of melatonin receptor agonists include dizziness and fatigue, as well as possible allergic reactions, and activity while asleep.
Orexin receptor antagonists: includes medicines like Suvorexant. This form of medication is not recommended for people who have Narcolepsy. Orexin receptor antagonists help one transition from wakefulness to sleep by inhibiting orexin neurons. Side effects include, but are not limited to, dizziness and headaches.
Benzodiazepines: includes medicines such as Lorazepam and Clonazepam. Benzodiazepines are sedatives that help slow down the brain and body’s functions to help you fall asleep easier. Side effects include dizziness, confusion and muscle weakness. They might also interfere with other medications so ensure you speak to a physician who is aware of your medical history before opting for benzodiazepines.

Over-the-counter medications:

Though you might not need a prescription to buy over-the-counter medications, it is crucial to let your doctor know what medications you are taking. Here are some common over-the-counter medications for insomnia:

Antihistamines: Diphenhydramine (Benadryl) and doxylamine are both antihistamines one can buy over the counter to treat insomnia. These two sedating antihistamines are usually recommended as a first-line medication for insomnia related to pregnancy. Side effects include drowsiness, dry mouth and constipation. Glaucoma patients and people with urinary retention difficulties should avoid treating insomnia with antihistamines as these medications have anticholinergic effects.
Melatonin supplements: The body creates melatonin naturally to help maintain a consistent sleep-wake cycle. Melatonin supplements are made in a lab and mimic the naturally occurring hormone, helping one fall asleep. Melatonin supplements don’t necessarily help someone stay asleep so if you suffer from nighttime wakefulness, it might not be what you are looking for. Side effects include daytime drowsiness, nausea and a spike in depression.

Dietary and herbal supplements:

What we consume plays a part in how well we sleep. Certain foods contain compounds that promote sleep or have sedating effects. For example, eggs, fish, nuts, cereals, mushrooms and legumes are good melatonin sources, helping maintain one’s natural circadian rhythm. Further, consuming high carbohydrate foods and foods containing tryptophan (like sunflower seeds, fish or cheese) or phytonutrients (like cherries or yams) have proven to promote sleep and tackle insomnia. Other herbal and natural supplements that aid sleep include hops, kava, valerian, magnesium and zinc. Cannabinoid therapies are increasingly demonstrating efficacy in treating insomnia.

The Role of Mental Health on Insomnia:

One’s mental health greatly affects one’s ability to sleep and one’s ability to sleep greatly affects one’s mental health. Treating insomnia correctly helps improve one’s mental health immensely and vice versa. Insomnia is often closely linked to depression, anxiety and post-traumatic stress disorder (PTSD). Meeting a mental healthcare specialist to treat an underlying mental health condition could considerably benefit one’s insomnia.

Preventing Insomnia

A combination of various lifestyle changes can help prevent or manage insomnia as well as the symptoms of insomnia. While it varies from case to case, depending on the cause of insomnia, things like healthier eating habits, exercise, a consistent sleep schedule or healthier bedtime rituals can greatly benefit sleeplessness.

How Does Insomnia Make You Feel?

Evidence shows that insomnia isn’t always serious, especially if one suffers from occasional bouts. Persistent or chronic insomnia can be a little more serious, with various short-term and long-term effects. Short-term effects include daytime sleepiness, lack of concentration or irritability while long-term effects include developing mental health and other medical disorders. Someone suffering from insomnia can expect to have difficulty falling or staying asleep. Some might even feel increased anxiety due to the inability to fall asleep, getting anxious nearer to bedtime. In other cases, some might feel like they aren’t rested or rejuvenated the next morning or day.

How Long Does Insomnia Last on Average?

The duration of insomnia depends on the type of insomnia one might be experiencing. Someone classified as suffering from chronic insomnia has at least three sleepless nights a week for three months or more. Short-term insomnia usually lasts under three months. Since insomnia has different effects on different people, speak with your doctor to understand how long you can expect to have other types of insomnia. Your doctor can give you a treatment plan accordingly.

Maintaining Better Sleep Hygiene

Sleeping better or getting sleep doesn’t follow a one-size-fits-all approach. Sleep hygiene is a set of practices and lifestyle modifications that help you get more restful sleep consistently. Some things you could do to improve your sleep hygiene are:

Maintain a consistent sleep schedule: irregular sleep patterns can confuse the body and throw off your natural sleep-wake cycle.
Establish healthy daily routines: stay active but avoid exercising, drinking liquids or consuming stimulants like coffee or alcohol late into the evening. Try not to go to sleep on an extremely heavy stomach either. Try spending some time in the sun.
Create a comfortable sleeping environment: set the temperature to something you’re comfortable with, try and invest in a comfortable mattress, dim the lights, block out as much noise as you can and make the environment as comfortable as possible so you can fall asleep and stay asleep.
Set up a nightly routine: create habits that help your body and mind associate with bedtime. Try relaxation techniques before going to bed, have a hot shower, avoid using electronics an hour before bedtime and don’t stay in bed if you can’t sleep after 20 to 30 minutes.

When Should I Consult a Doctor for Insomnia?

It is normal to not be able to sleep every now and then. Although, if you consistently cannot fall asleep, it’s probably a good idea to meet a doctor or sleep specialist. Before you do see a doctor though, if the insomnia isn’t affecting your daily life considerably, you might want to try developing healthier sleep habits first. If you still find yourself with insomnia-like symptoms despite incorporating healthier sleep habits, reach out to your doctor. It is possible that something more serious could be causing disturbed sleep and a doctor can help you make the correct diagnosis. Consult your doctor for insomnia if:

You have trouble falling or staying asleep
Do not feel rested on waking up and experiencing fatigue throughout the day

Insomnia and Pregnancy

Pregnant women often face insomnia. It becomes hard to fall asleep or stay asleep due to high hormonal levels as well as physical changes. Psychological factors play into sleeplessness during pregnancy too. If signs of pregnancy-related insomnia show, it is recommended to treat it as early into the pregnancy as possible. Approaches that don’t involve consuming pharmacological drugs are recommended, like CBT-I. If you do opt for pharmacological approaches, evaluate closely with your doctor the potential disadvantages and advantages of the drug you are considering to treat insomnia during pregnancy. Speak to a doctor to develop a plan to treat insomnia during pregnancy anyway, as they can guide you on how various treatments might influence your unique case.