Insomnia is a common sleep disorder characterized by difficulties in falling asleep, staying asleep, or experiencing a decline in sleep quality. There is no distinction between the terms “insomnia” and “sleeplessness,” so both are used interchangeably in medicine.
When classifying insomnia, which is a type of dyssomnia (a broader concept describing sleep problems), the predominant sleep pattern is taken into account. Types of sleep disturbances include:
- Insomnia at sleep onset (difficulty falling asleep for a long period of time)
- Middle-phase insomnia (multiple awakenings and falling asleep again throughout the night)
- Early morning awakening.
Insomnia can be acute (short-term), transient, or chronic (long-lasting or regular). It can also be categorized into primary and secondary insomnia.
Primary Insomnia
Primary insomnia is a disorder that is not directly associated with existing diseases. One of the distinguishing features of primary (psychophysiological) insomnia is the absence of a progressive or past psychiatric disorder.
Secondary Insomnia
Secondary insomnia is a symptom or complication of diseases, stress, fatigue, or a result of harmful habits, poor nutrition, or medication use. Common causes of secondary insomnia in both men and women include physiological and mental disorders.
Symptoms of Insomnia Due to Mental Disorders
Among the symptoms characteristic of acute and chronic insomnia are frequent nighttime awakenings. Other symptoms include:
- Difficulty falling asleep (no sleep within 30 minutes of the first attempt)
- Early awakening
- Daytime sleepiness
- Reduced performance and concentration
- Irritability, depression, or anxiety
- Worrying about sleep problems.
Insomnia may also be accompanied by memory impairment. Another common symptom of insomnia is chronic fatigue.
Psychiatric Causes of Insomnia
Insomnia is a common complication of depression. Other causes of insomnia include:
- Seasonal affective disorder
- Panic attacks
- Anxiety disorders
- Attention deficit hyperactivity disorder (ADHD)
- Bipolar disorder
- Parasomnias (e.g., sleepwalking or nightmares)
- Post-traumatic stress disorder (PTSD)
- Schizophrenia
- Dementia
- Phobias.
Insomnia often develops against the background of nervous system diseases. In this case, treatment may be complex and conducted under the supervision of a psychiatrist and neurologist.
Medication-Induced Insomnia
Medication-induced insomnia can result from the abuse of psychotropic and non-psychotropic drugs. Medications that can cause insomnia include:
- Antibiotics like a (Augmentin, Doxycycline)
- Medications prescribed for cardiovascular diseases (e.g., beta-blockers)
- Anti-asthmatic drugs
- Sleep aids
- Antihistamines
- Sedatives
- Antidepressants
- Diuretics
- Anti-anxiety medications
- Antipsychotics
- Anti-cancer drugs
- Nicotine replacement products
- Cholesterol-lowering medications
- Muscle relaxants
- Decongestants
- Proton pump inhibitors
- Anti-seizure medications
- Steroids
- Medications used in the treatment of Parkinson’s disease.
Providing a psychiatrist with a list of currently used medications is an important step in diagnosing insomnia. It is also necessary to clarify the duration and dosage regimen of each drug.
Adjustment Insomnia
Adjustment insomnia is diagnosed if sleep disturbances occur at least three days a week for a period ranging from seven days to three months. Types of adjustment insomnia include:
- Acute (lasting 3-14 days)
- Transient (lasting two to four weeks)
- Subchronic (lasting from one to three months).
From an evolutionary perspective, the occurrence of adjustment insomnia may be explained by the development of response mechanisms to circumstances where there is a threat to life or health. Adjustment insomnia often occurs as a reaction to situational stress (e.g., a job change, an approaching deadline, or an exam). Adaptation to stressors helps reduce the frequency of insomnia episodes and improve sleep.
Psychophysiological Insomnia
Psychophysiological insomnia is a type of chronic insomnia characterized by increased focus on sleep issues or worry about sleep disturbances (e.g., unsuccessful attempts to fall asleep). Consequently, there are difficulties falling asleep in familiar surroundings at the desired time, dissatisfaction with sleep, and daytime sleepiness.
A common cause of psychophysiological insomnia in both men and women is stress, and sleep disturbances may persist even long after the stressful event has passed. Some patients experience anxiety about the prospect of another sleepless night long before bedtime and spend hours in bed awake, focusing on their insomnia.
Paradoxical Insomnia
Paradoxical insomnia (subjective insomnia or incorrect perception of sleep) is a subtype of insomnia where the patient’s complaints about sleep disturbances (e.g., daytime sleepiness) do not align with the actual clinical picture. Paradoxical insomnia may involve underestimation of total sleep duration or incorrect perception of the time spent falling asleep and waking up.
Paradoxical insomnia may be accompanied by stress, anxiety, and fatigue. The risk of paradoxical insomnia increases with heightened excitability of the cerebral cortex, which may be exacerbated by depression, anxiety, schizophrenia, bipolar disorder, obsessive thoughts, or alcohol addiction.
Types of Insomnia
The main criterion for determining the type of insomnia in adults is the duration of sleep disturbances. Acute, transient, and chronic insomnia are distinguished based on this criterion.
Acute (Short-Term) Insomnia
Short-term insomnia, lasting no longer than three months, often occurs in response to a provoking stressor (e.g., workplace issues, family conflicts, or a traumatic event). Attempts to combat daytime fatigue with energy (e.g., caffeine) drinks negatively impact sleep quality. Since stress is the main triggering factor for short-term insomnia, its frequency decreases as the impact of stress diminishes.
Acute insomnia may develop into chronic insomnia, especially with maladaptive sleep behaviors. For example, going to bed too early may increase the time spent in bed and lead to frustration over the prolonged time taken to fall asleep.
Transient Insomnia
Transient insomnia may occur suddenly as a result of changing external conditions. For example, the causes of transient insomnia may be travel, shift work, or noise exposure. Transient insomnia, which typically lasts from one to four weeks, can also be a complication of acute illnesses affecting various systems.
Chronic Insomnia
Chronic insomnia is a persistent form of insomnia. It lasts for at least three months. The causes of chronic insomnia may include:
- Depression
- Post-traumatic stress disorder
- Increased sleep sensitivity
- Frequent episodes of acute insomnia.
Risk factors also include specific personality traits (e.g., perfectionism, neuroticism, introversion, and susceptibility to anxiety) or experiences of psychosocial stress (e.g., divorce or job loss). The consequences of untreated chronic insomnia can include exacerbations of depression, reduced productivity, and a lower quality of life. One of the most dangerous and rare forms of chronic insomnia is fatal familial insomnia.
Diagnosis and Treatment of Insomnia
If insomnia symptoms occur, it is necessary to schedule an appointment with a doctor. Insomnia is treated by a psychiatrist. Diagnosis of insomnia includes:
- Medical history (including information on medications, comorbid conditions, predominant complaints, the time of their onset, and factors that may have triggered insomnia)
- Sleep diary (for tracking the time of falling asleep, waking up, and sleep problems throughout the day)
- Electroencephalography (to study the electrical activity of the brain)
- Laboratory blood and urine tests.
If necessary, the psychiatrist may refer the patient to other specialized professionals. For example, to regulate sleep in cases of neurosis, headaches, and impaired coordination, a consultation with a neurologist is recommended. For insomnia accompanied by blood pressure fluctuations and excessive sweating, consultation with a cardiologist is suggested.
Treatment regimens for acute, transient, and chronic insomnia depend on the diagnostic results. Insomnia treatment methods include:
- Lifestyle adjustments (e.g., daily routine and work schedule)
- Cognitive-behavioral therapy
- Avoiding alcohol, caffeine, and smoking
- Regular physical exercise (no later than five to six hours before sleep)
- Avoidance of daytime naps (if nighttime sleep is problematic)
- Avoiding late dinners
- Massage therapy (to relieve tension)
- Courses of medication.
In the context of medication-based treatment for acute and chronic insomnia, drugs that promote falling asleep and maintaining sleep (e.g., orexin receptor antagonists, antidepressants, anticonvulsants, sedatives, or hypnotics) may be used. It is also necessary to discontinue medications that may cause sleep disturbances (in consultation with a doctor).
To cope with insomnia, it is essential to maintain sleep hygiene. Regular ventilation and cleaning of rooms, minimizing noise, vibration, bright lights, extreme temperatures, excessive humidity, or dry air can improve sleep quality without medication. Another method for combating insomnia is reducing the influence of additional stressors (e.g., avoiding computer games and watching action-packed movies) before sleep.
