Insomnia as a Symptom: Causes, Conditions, and Prevention

Key Takeaways:

• Insomnia involves frequent difficulty falling and/or staying asleep, which also impairs daytime functioning and well-being. Insomnia can be short-term or chronic.

• Insomnia is more common in individuals with mental health disorders (e.g., anxiety, depression, PTSD), as well as women, the elderly, and anyone under significant stress.

• Psychotherapy is the first-line treatment for insomnia, while medication may be added on if needed. Sleep hygiene and other self-management practices also help.

What is Insomnia?

Insomnia refers to frequent trouble falling and/or staying asleep. It also often causes early awakenings and difficulty falling back asleep. In general, individuals with insomnia have the opportunity to sleep enough hours, but their sleep issues prevent them from getting adequate sleep, which can lead to disruptions in energy, mood, performance, and overall well-being.  [1] [2]

How Common is It?

Insomnia as a symptom is relatively common, affecting 33 to 50% of people in the general population at some point. The overall prevalence of insomnia disorder, which has stricter criteria, ranges from 10 to 15% of the population. [3] [4]

Is Insomnia a Condition or a Symptom?

Insomnia can be a condition or a symptom, depending on the exact situation, although it is most often viewed as a diagnosable condition. Specifically, insomnia symptoms can be caused by other factors, such as stress, pain, or mental health disorders. However, insomnia is also a formally recognized condition, specifically referred to as insomnia disorder in the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition, text revision; DSM-5-TR), as well as the International Classification of Sleep Disorders (3rd edition; ICSD-3). [3]

Types of Insomnia

There are two primary types of insomnia:

• Short-term insomnia.

• Chronic insomnia.

Short-term insomnia usually lasts several days to weeks. It is often due to specific stressors or other causal factors, such as work stress, family conflicts, or trauma. Short-term insomnia usually resolves once the stressors are gone, although it can sometimes lead to chronic insomnia. [1] [2]

(It should be noted that short-term insomnia is slightly different by definition than the DSM-5-TR criteria for episodic insomnia, which is insomnia that lasts longer than 1 month but less than 3 months.) [4]

Lastly, chronic insomnia is characterized by having insomnia symptoms on at least 3 nights per week for longer than 3 months. It is officially referred to as persistent insomnia in the DSM-5-TR. [1] [4]

Common Symptoms

Insomnia symptoms may vary slightly from person to person, although the overall presentation is generally similar. Listed below are the most common insomnia symptoms: [2] [3] [4]

• Trouble falling asleep

• Difficulty staying asleep

• Waking up too early

• Frequent awakenings in the middle of the night

• Difficulty falling back asleep after waking up

Insomnia may also cause certain symptoms during the day, such as: [2] [3] [4]

• Tiredness or fatigue

• Moodiness or irritability

• Depression

• Anxiety

• Trouble with focus or concentration

• More errors, accidents, or decreased performance (e.g. at school or work)

• Decreased energy and vitality

• Worry about lack of sleep

Mental Health Conditions Associated with Insomnia

Many mental health conditions are associated with insomnia. This includes: [3] [4]

• Anxiety

• Depression

• Post-traumatic stress disorder (PTSD)

• Schizophrenia

• Bipolar disorder

In general, insomnia and other sleep disorders occur at higher rates in individuals with mental health disorders compared to the general population. For example, 70 to 80% of psychiatric patients have shown some sleep disturbance, compared to 33 to 50% of the general population. [3]

Part of the reason for the high rates of insomnia in individuals with mental health conditions is due to bidirectional effects. The stress and other disruptions from mental health conditions can make it difficult to sleep, and these sleep disruptions in turn may worsen mental health disorders. [3]

Condition-Specific Symptoms

Anxiety disorders: 

• Difficulty falling asleep

• Frequent awakenings

Schizophrenia and psychotic disorders: 

• Serious difficulty falling asleep

• Partial or complete inversion of normal day-night cycles

• Polyphasic sleep patterns

Depression: 

• Early-morning awakenings

• Broken, unrefreshing sleep

PTSD:

• Nightmares

• Fragmented sleep

Who is at Risk of Having Insomnia?

Many situations increase the risk of having insomnia. Listed below are certain populations who have a higher than average risk of insomnia: [1] [2] [4]

• Elderly

• Women

• Individuals with mental health disorders (e.g. depression, anxiety, PTSD)

• Individuals with significant life stress

Other risk factors for insomnia include: [2] [4] [5]

• Frequent travel

• Changing work shifts (Also, work shifts not aligned with your body’s natural rhythms)

Certain medications, such as:

• Blood pressure drugs

• Antidepressants

• Corticosteroids

• Asthma medications

• Certain over-the-counter pain, allergy, or cold medicines

Medical conditions, such as:

• Chronic pain

• Diabetes

• Cancer

• Heart disease

• Asthma

• Overactive thyroid

• Parkinson’s disease

• Alzheimer’s disease

• Gastroesophageal reflux disease (GERD)

• Stimulant consumption (e.g., caffeine, nicotine)

Certain personality traits, such as:

• Excessive worry

• Perfectionism

• Neuroticism

Insomnia in Young People

Children and teens can also experience insomnia. Sometimes, this is due to school schedules that do not align with young people’s shifted circadian rhythms, in which they naturally want to go to bed and wake up at later times. [2]

Children may also rely on certain routines and stimulations, such as storytelling, rocking, or favorite toys. If these are not available, this may cause anxiety or fear, which can cause insomnia. [4]

Lastly, several developmental issues can cause sleep disturbances, such as delayed milestones, hyperactivity, and separation anxiety. [4]

Insomnia in the Elderly

Older adults, especially those over aged 65, have an increased risk of insomnia. There are several reasons why elderly individuals are more likely to have insomnia, such as: [2]

• Changes in sleep patterns

• Age-related decrease in restful sleep

• Lack of physical or social activity

• Greater prevalence of health conditions

• Greater prevalence of medication usage

Prevention

Insomnia can’t always be prevented, but you can often take steps to decrease the risk of its development. Practicing good sleep hygiene habits, managing stress, and getting properly treated for any health conditions you have are all ways to minimize the risk of insomnia.

Diagnosing Insomnia

Insomnia is diagnosed by a healthcare professional. The diagnostic process typically starts with a physical exam and an overview of medical history, performed by a primary care doctor. They’ll ask about your sleep history and general sleep habits to gain more important information.

The next steps consist of a variety of tools to gain insight about the unique symptoms, which is done through interviews, observations, scales, questionnaires, or other measures. With this information, healthcare professionals compare the symptoms to the diagnostic criteria found in professional manuals, such as the DSM-5-TR and the ICD-3. [3]

Tests and Assessments

A variety of tests and assessments may be used to help diagnose insomnia. One of the most basic assessments is a sleep diary, which patients use to track their sleep time, total time in bed, awakenings, and to gain insight into how certain habits or other factors (e.g., alcohol, naps) affect sleep. [6]

While a sleep diary provides useful insight, more objective tests and measures are usually used as well, such as: [6]

• Insomnia Severity Index (ISI): This widely used scale contains 5 questions on a 5-point scale that measure the overall severity of insomnia.

• Pittsburgh Sleep Quality Index (PSQI): The PSQI contains 19 questions to gain insight about sleep quality, sleep disturbances, sleep duration, and other important sleep factors.

• Epworth Sleepiness Scale (ESS): The ESS measures how likely someone is to fall asleep in various situations, which helps identify sleepiness and potential sleep issues.

• Sleep Condition Indicator (SCI): The SCI consists of 8 questions on a 5-point scale to measure insomnia symptoms and their effect on overall functioning and life quality.

• Actigraphy: This assessment utilizes a wrist actigraph, which measures movements during sleep and waking hours. It can help identify sleep duration, sleep latency, and other important measures.

• Sleep Study: Sometimes, a formal sleep study may be needed. This takes place overnight in a medical facility and measures how well you sleep. It can also be used to identify sleep disorders, such as sleep apnea. [5]

Imaging or lab work may also be needed in some cases. However, this is not typically required.

Treatment for Insomnia

The most common treatments for insomnia are psychotherapy and medication. This is also usually combined with education and self-management strategies.

Psychotherapy is considered the first-line treatment for insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is the most widely used and recommended psychotherapy treatment. CBT-I consists of several key components, including: [3] [4] [6]

Sleep restriction therapy: This limits the amount of time someone spends in bed in order to improve sleep efficiency.

Stimulus control therapy: This therapy ensures that the bedroom is only used for sleep, and also incorporates other sleep “rules”, such as:

• Only going to bed when truly sleepy

• Getting up out of bed if you can’t sleep after 15 to 20 minutes

• Maintain a consistent sleep/wake schedule

Sleep hygiene: This portion of treatment educates individuals on how to improve sleep through various sleep hygiene habits, such as:

• Ensuring a quiet, dark, and comfortable room

• Limiting naps

• Avoiding alcohol, caffeine, big meals at night, or other factors that disrupt sleep

Various forms of relaxation therapy may also be used for insomnia, especially if insomnia is due to stress or anxiety. Examples of relaxation therapies include breathing exercises, yoga, meditation, and progressive muscle relaxation.

Medications are typically only used after trying the non-medication options first. The most common medications used for insomnia are: [4] [6]

• Benzodiazepine receptor agonists (BRAs) (e.g., zolpidem, zaleplon)

• Benzodiazepines (e.g., temazepam, triazolam)

• Orexin receptor antagonists (e.g., suvorexant, lemborexant)

• Melatonin

• Melatonin agonists (e.g., ramelteon)

• Certain antidepressants (e.g., trazodone, mirtazapine)

Living with Insomnia

Insomnia can make daily life difficult in many ways. However, insomnia doesn’t have to take over your life. If you have insomnia, make sure to stay connected with your healthcare provider. They can often help you with pain, stress, or any health conditions that may be affecting your sleep.

Tips to Help With Insomnia

In addition to professional help, there are many things you can do to help with insomnia. Try any of the following insomnia tips: [7]

• Go to bed and wake up at the same time each day

• Limit or eliminate anything in the evening or night that commonly disrupts sleep, such as:

  • Alcohol

  • Nicotine

  • Caffeine (some may need to avoid earlier on in the day as well)

  • Heavy meals

  • Intense exercise

  • Heavy fluid intake

• Limit or avoid naps

  • If you do nap, try to make it no longer than 30 minutes

  • If you sleep at a regular nightly hour, don’t nap later than 3 or 4 pm

• Engage in regular exercise and activity

• Only use your bedroom for sleep

• Make sure your bedroom is dark, cool, and quiet

• Consider the use of earplugs, an eye mask, a noise machine, and other tools to optimize your sleep environment

• Implement a “wind-down routine” with any of the following about an hour before bed:

  • Warm bath

  • Reading

  • Listening to gentle music

  • Yoga

  • Meditation

  • Prayer

• Get out of bed if you can’t sleep

  • Do a non-stimulating activity (e.g., reading) until you’re sleepy again

Takeaway

Insomnia is not just a nighttime issue, as it also leads to daytime impairments and detriments to general well-being and ability to function. If you’ve been experiencing symptoms of insomnia, reach out to a healthcare professional. The sooner you get treated, the more likely it is that your insomnia will resolve.