Everyone has a restless night now and then. In addition, people who travel or who experience a change in their work routine often go through a period of adjustment where sleep is erratic or unsatisfying. In most cases, however, these difficulties work themselves out and the person returns to normal sleep.

But if that one restless night has turned into several in a row, or several over the course of a week or two, then the person is said to suffer from acute insomnia. If this restless state continues for a month or more, then the person has entered the realm of chronic insomnia.

What is Insomnia?

According to researchers at the Perelman School of Medicine at the University of Pennsylvania up to 25% of all Americans experience short term, or acute, insomnia each year (1). That’s some 90 million Americans. Insomnia is a multifaceted sleep disorder that does not exhibit a single pathology, but instead may have any one of a multitude of causes and manifest itself in a variety of different ways.

For some people, insomnia means they have difficulty falling asleep. For others, insomnia means they can get to sleep but cannot stay asleep for very long. Other people wake up earlier than they planned and cannot get back to sleep. While still others wake up repeatedly during the night for various reasons. Insomnia may be a problem unto itself, but in most instances it is the result of some underlying cause or condition. Let’s look at those potential causes now.

Causes of Insomnia

Insomnia is a symptom of some form of hyperarousal (2). This agitated state may be the result of illness or stress, or it could be caused by medication or lifestyle, or it may be a manifestation of more serious mental health issues. Here are the most common causes of insomnia.

Stress – When people are concerned about work, health, money, school, relationships and other issues they can have a hard time getting to sleep. Stress is a common catalyst for mental activity, but it’s often a very specific type of mental activity (3) related to the survival instinct. Not the kind of thoughts that are going to promote deep, restful sleep.

Illness or injury – People in physical pain from an illness or injury often have a difficult time falling asleep. For instance, both osteoarthritis (4) and rheumatoid arthritis (5) can, and do, negatively affect sleep quality and duration. In addition, men with an enlarged prostate or BPH (6) will often have to rise several times during the night to relieve themselves.

Long distance travel – Every person has their own internal clock that’s silently running the show. These circadian rhythms (7) regulate everything from metabolism, to body temperature to, most famously, when you go to sleep and when you wake up. Long distance travel across multiple time zones disrupts these natural rhythms resulting in what we call “jet lag”. Most of the time jet lag resolves itself in a few days. But when people engage in frequent long distance travel it can create chronic insomnia.

Mental health disorders – There are numerous mental health issues that can negatively affect a person’s ability to sleep including depression, anxiety, bipolar disorder (8), and PTSD or post traumatic stress disorder (9). Exactly how these conditions interfere with sleep is not fully understood, but the insomnia they cause often becomes part of a vicious cycle that winds up exacerbating the underlying condition.

Caffeine – While coffee is no longer considered dangerous for your health (10), caffeine can and often does, interfere with sleep. Caffeine is the most popular stimulant the world has ever known and some people just can’t seem to get enough of it. But if you’re drinking coffee or other caffeinated beverages in excess, or too close to bedtime, it can cause you to lie awake staring at the ceiling.

Certain medications – Some prescription drugs are known to interfere with a person’s ability to sleep. Antidepressants, for instance, are known to sometimes cause sleepless nights (11). Therefore it is critically important to take them exactly as prescribed, and if they cause insomnia, to talk to the prescribing doctor before tweaking the treatment on your own.

Cognitive disorders – People with Parkinson’s disease or Alzheimer’s disease often have a hard time sleeping (12)(13). Researchers do not entirely understand the link between such cognitive disorders and sleep disruption, but the evidence leaves little doubt that such a link exists.

Lifestyle choices – People who go to sleep at different times every day, drink lots of coffee, take naps late in the day, or take their smartphone or tablet to bed with them often suffer from bouts of insomnia. Whether we like it or not our bodies crave routine. By abandoning all semblance of a regular schedule a person sets themselves up for sleepless nights.

Eating too much, too late – Having a large meal shortly before going to bed is a bad idea for many reasons. For one thing, it can interfere with a person’s ability to get to sleep. They may lie in bed feeling bloated and finding it difficult to assume a comfortable position. They may also experience heartburn or be awakened by GERD (14) in the middle of the night.

There may be other causes of insomnia, and quite frankly, not every case of insomnia can be traced to a specific cause. But the above represent the most commonly diagnosed causes.

What are the Risk Factors for Insomnia?

The occasional sleepless night, while annoying, is not unusual. Insomnia is something that lasts for at least a few days, and in some cases, for weeks or even months. The risk factors for insomnia then are:

Being over 60 – People’s physiology changes throughout their life. By the time we reach 60 our bodies don’t need as much sleep as they used to, although scientists are not exactly sure why. That said, some cases of insomnia in older adults can be traced to other health issues, such as BPH and arthritis, as well as more severe conditions like Parkinson’s and Alzheimer’s.

The presence of mental health disorders – Depression, anxiety, bipolar disorder and other mental health issues are known to disrupt sleep. Certain medications taken to combat these conditions also have the effect of making it harder to sleep.

Being female – Women undergo significant hormonal activity during their menstrual cycle (15). This may cause insomnia in some of them. Many women experience intense cramping during their menstrual cycle as well, and this can definitely interfere with the ability to get to sleep. In older women, hot flashes and night sweats during menopause can also cause insomnia.

Having an erratic schedule – Some people have jobs that require them to alternate between day work and night work. Others get to bed at a different hour every night. And still other people travel a lot and find themselves dealing with different time zones on a regular basis. All these things can cause insomnia.

Being under stress – Stress may be the most common risk factor for insomnia. Stress affects people of all ages and backgrounds and can have a plethora of different triggers including school, work, relationships, global events, health, death of a loved one and many more.

Diagnosing Insomnia

Because there are so many potential causes of insomnia there is no one specific test that will result in an ironclad diagnosis. Unless there is an obvious cause it may take some time to confirm a diagnosis of insomnia and to nail down what is behind it.

Therefore your doctor will typically start the process of diagnosing insomnia by asking about any recent medical conditions, changes to your work schedule, or changes in your personal life. If none of these lines of inquiry produce useful results, your doctor may ask you to keep a sleep log in a attempt to nail down the cause.

A sleep log typically consists of:

• Recording when you fall asleep (as best you remember)
• Recording when you wake up
• How many times (if any) you wake up during the night
• Why you wake up (bathroom visit etc.)
• Whether you have difficulty falling back to sleep

The sleep log will often help paint a clearer picture of your insomnia. However, if it doesn’t, your doctor may order certain medical tests, such as blood work, to try and get to the heart of the matter. If they suspect it is necessary they may also suggest a psychological evaluation to determine if there is a mental health issue behind your sleeplessness.

In some instances your doctor may recommend a more involved process called a “sleep study” (16). A sleep study does not mean that you participate in an organized, long-term study involving many individuals. Instead, it means either checking into a sleep center where you will be observed overnight, or essentially doing the same type of observation in your own home.

During the sleep study electrodes are attached to the body that are used to record brain waves and muscle activity while you sleep. This information will help your doctor rule in or rule out a number of potential causes for your insomnia.

Insomnia and Older Adults

As people age insomnia tends to become more common. As we touched on briefly above there are a number of potential reasons for that. Let’s take a closer look at some of those reasons now.

A lack of physical activity – As they get older most people become significantly less active, both physically and socially. Not expending any energy during the day can make it more difficult to get to sleep at night. Regular exercise has been shown to improve sleep quality in adults of all ages, including those over 60.

Health issues – Unfortunately, aging and health issues tend to go hand in hand. Conditions such as arthritis can make it very difficult to find a comfortable sleep position. The skeleton in general undergoes numerous changes as we age (17), and one of the results of these changes is back pain that can make it difficult to get comfortable in bed.

Taking naps – Who would have thought that taking a nap could be a bad thing? But in some cases it is. Many older folks are fond of taking lengthy naps late in the day. The problem with such a habit is that it can interfere with their ability to fall asleep and stay asleep at night. Something of a vicious cycle then ensues where the nap is used to compensate for the lack of night time sleep that the nap is causing.

Medications – All those health conditions that tend to afflict older folks often bring with them the need for medication to alleviate symptoms. Drugs that can and often do interfere with sleep include beta-blockers, anti-arrhythmics, diuretics, antidepressants, antihistamines, corticosteroids and more.

If you feel medication is causing insomnia talk to your doctor about possible alternatives or adjusting your dosage or treatment regimen.

How is Insomnia Treated?

Because there are different types of insomnia, as well as different causes, there are different approaches to treatment. Here we’ll look at the different treatments for both short-term (acute) insomnia and long-term (chronic) insomnia.

Treatments for Acute Insomnia

Unless there is an obvious cause for a person’s insomnia the doctor will typically suggest the adoption of certain lifestyle changes to treat short-term insomnia. These changes may include:

• Making certain that you go to bed and wake up at the same time every day.
• Never drinking caffeinated beverages after dinner.
• Eliminating naps altogether.
• Not taking a smartphone or tablet into the bed with you.
• Turning the thermostat down in your room, since cool temps are better for sleeping.
• Getting out of the habit of lying in bed awake. If you cannot sleep after 20 minutes, get up and do something. Do not return to bed until you are drowsy.
• Not having a clock staring at you from the bed stand.

If these adjustments do not yield the desired result your doctor may suggest something more proactive such as…

• Advanced slow breathing techniques.
• Dietary supplements including melatonin or valerian (18).
• Cognitive behavioral therapy.

Cognitive Behavioral Therapy Explained

Cognitive behavioral therapy is a non-medication treatment designed to address the kind of thoughts and behaviors that may be preventing you from getting the sleep you need. Ideally, you would learn to replace anxiety over sleeping with more positive thoughts and limit the amount of time you spend in bed awake. Typically you would meet with the sleep therapist weekly for a period of several months either in individual or group sessions.

During the therapeutic period the doctor or sleep therapist may try various other techniques including,

Changing the sleep environment – This is exactly what it sounds like in that you modify the environment in your bedroom to make it more conducive to sleep. That typically means eliminating sources of light and noise, and may include something like changing your mattress.

Eliminating behaviors that cause your brain to be stimulated – People with insomnia often get agitated at the very notion of trying to fall asleep, which only exacerbates the problem. This aspect of cognitive behavioral therapy then focuses on developing ways to replace the thought processes that lead to this counterproductive stimulation.

Engage in biofeedback therapy – Biofeedback (19) is intended to help a person gain greater control over their body in order to transcend various difficulties, including insomnia and pain. Biofeedback information is gathered through the use of electronic sensors that are attached to the body in different places such as the scalp, palms, chest or fingers.

Decreasing how much time you spend in bed awake – This technique, known as sleep compression (20), aims to reduce the amount of time a person spends in bed when they are not sleeping. Useful information to guide this process can often be gleaned from a sleep diary. Normally, this type of therapy is only recommended for those who feel like they get less sleep than they actually do, and this perception is affecting their waking performance.

Chronic Insomnia Treatments

Treatment of chronic insomnia often takes the form of cognitive behavioral therapy, which we just described above. Should that fail to produce the desired result, your doctor may decide that some form of medication is required. The following are some of the most commonly prescribed medications to treat insomnia.

Benzodiazepines – Benzodiazepines (21) or BZDs are a type of psychoactive drug. There are 5 BZDs that have gained FDA approval for the treatment of insomnia. They are characterized as having either short, medium or long-term effects. Because BZDs are potentially addictive they are not typically prescribed for chronic insomnia, where the patient might have to take them for weeks or months at a time.

Ramelteon – Ramelteon (22) falls into a category of medications known as melatonin receptor agonists. It’s action is similar to that of melatonin, which helps the brain regulate our sleep/wake cycle. Ramelteon is often used to treat insomnia because it is considered less severe than benzodiazepine, with less chance of the patient developing physical or mental dependency. Some people who take Ramelteon, however, complain of side effects including dizziness, fatigue and nausea.

Orexin receptor antagonist – Orexin is a neurotransmitter in the brain that helps people stay awake and alert. As the word “antagonist” implies, an orexin receptor antagonist blocks the action of orexin, thereby making it easier for a person to fall asleep. Suvorexant (23) is a commonly prescribed orexin receptor antagonist often sold under the brand name Belsomra.

Nonbenzodiazepines – This type of drug was created to produce effects similar to benzodiazepines but with a much-reduced risk of addiction. One of the most common nonbenzodiazepines is Ambien (24). Ambien is widely prescribed to help people with insomnia, but it is a Schedule IV controlled substance and will require a prescription.

Over the counter medications – Over the counter, or OTC, medications for insomnia include melatonin and valerian supplements as well as certain antihistamines. One has to be careful with antihistamines, however, because some can cause sleeplessness.

Do Children Suffer From Insomnia?

Children often suffer from insomnia for many of the same reasons adults do, including:

Stress – Things like moving to another town, the first day of school, and getting bullied can all cause huge amounts of stress for a child.

Mental health disorders – Many of the mental health issues that plague adults have their origins in childhood. For instance, children who suffer physical or sexual abuse often experience PTSD as adults (25).

Family problems – Approximately 40% of all marriages in America end in divorce. And while divorce is difficult on the husband and wife it can be even more difficult on the kids who are losing the domestic stability they instinctively rely on. Another source of stress for young kids is when a parent marries a different spouse who has kids of their own.

Medications – Children are often prescribed Ritalin (26) as a treatment for hyperactivity. But Ritalin brings with it a host of potential side effects including insomnia (27).

The same methods used to treat insomnia in adults are often used to treat insomnia in children. That means making the bedroom more sleep friendly, reducing stress and going to bed at the same time, etc.

Anxiety and Insomnia

Anxiety and insomnia sometimes act as a kind of two-headed monster that feed off of and aggravate one another. Anxiety can be a major contributing factor to insomnia. Once the insomnia sets in it, in turn, aggravates the anxiety as the person worries they won’t get enough sleep to function properly. More anxiety leads to more insomnia and the downward spiral begins.

But not all types of anxiety are the same or have the same outcomes. For instance, anxiety may be a short term phenomenon related to a specific event or specific events. This type of anxiety can disrupt sleep for a time, but the anxiety often goes away once the triggering event is resolved. When that happens, sleep typically goes back to normal as well.

There is no single approach that is used to treat insomnia related either directly or indirectly to anxiety. Treatment depends almost entirely on the particular person and events and may be influenced by the person’s medical history, age, environment and other factors.

Complications Stemming from Insomnia

Insomnia does not exist in a vacuum. It typically has a cause that can be uncovered and it often produces complications that can range from the mild to the serious. Chronic insomnia in particular can aggravate or increase a person’s risk for a number of different health problems including:

• Depression
• Asthma
• Seizures
• Stroke
• Obesity
• Type 2 diabetes
• High blood pressure
• Memory loss
• Heart disease
• Weakened immune system
• Sexual dysfunction

Conclusion

Insomnia is a vexing problem that can be extremely disruptive and sometimes resists effective treatment. At the same time, it is important to note that the occasional sleepless night is normal and is not a cause for concern in and of itself.

That said, if you have experienced difficulty getting to or staying asleep for more than a few weeks, and cannot trace the insomnia to any particular event, you should raise the issue with your doctor.