Insomnia Podcast Transcript

Welcome to the National Heart, Lung, and Blood Institute podcast on insomnia. This podcast will discuss what insomnia is and the causes, risk factors, and signs and symptoms of insomnia. It also will discuss how insomnia is diagnosed and treated.

More information, including "Your Guide to Healthy Sleep," is available on the NHLBI Web site at www.nhlbi.nih.gov or by calling the NHLBI Health Information Center at 301–592–8573.

What Is Insomnia?

Insomnia is a common health problem that causes people to have trouble falling or staying asleep. Some people with insomnia may fall asleep easily but wake up too soon. Other people may have the opposite problem, or they have trouble with both falling asleep and staying asleep. The end result is poor-quality sleep that doesn't leave you feeling refreshed when you wake up.

Insomnia can be mild to severe depending on how often it occurs and for how long. Chronic, or long-term, insomnia means having symptoms at least 3 nights per week for more than a month. Insomnia that lasts for less time is known as short-term or acute insomnia.

Insomnia causes excessive daytime sleepiness and a lack of energy. Long-term insomnia can cause you to feel depressed or irritable. You also may have trouble paying attention, learning, and remembering—and you may not do your best on the job or at school. Insomnia also can limit the energy you have to spend with friends or family.

There are two types of insomnia—secondary and primary. The most common type is secondary insomnia. It's believed that more than 80 percent of people with insomnia have this type.

Secondary means that the insomnia is a symptom or a side effect of some other problem. Some illnesses, like heart and lung diseases, may cause secondary insomnia. Pain, anxiety, and depression also can cause this condition.

Other factors can contribute to secondary insomnia as well, such as medicines that disrupt sleep, and caffeine, tobacco, alcohol, and other substances that affect sleep. Other sleep disorders, a poor sleep environment, or a change in your sleep routine also can contribute to secondary insomnia.

Secondary insomnia often goes away or improves without treatment if you can eliminate its cause. This is especially true if the problem is corrected soon after it starts.

Primary insomnia is not a side effect of medicines or another medical problem. It is its own disorder, and generally persists for least a month or longer.

Better sleep habits and lifestyle changes often help relieve insomnia. You may need to see a doctor or sleep specialist if you have long-term or recurring insomnia, or if you don't know what's causing the condition.

What Causes Insomnia?

There are two types of insomnia—secondary and primary.

Secondary insomnia is the most common type. It's often a symptom of an emotional, neurological, or other medical disorder, or of another sleep disorder.

The emotional disorders that can cause secondary insomnia include depression, anxiety, and posttraumatic stress disorder.

Alzheimer's disease and Parkinson's disease are examples of common neurological disorders that can cause secondary insomnia.

A number of other diseases and conditions also can cause secondary insomnia, including:

• Conditions that cause chronic pain, such as arthritis and headache disorders,
• Conditions that cause difficulty breathing, such as asthma or heart failure,
• Overactive thyroid,
• Gastrointestinal disorders, such as heartburn, and
• Stroke.

Sleep disorders, such as restless legs syndrome, also can cause secondary insomnia. Sometimes secondary insomnia is a side effect of some medicines or commonly used substances, such as:

• Caffeine or other stimulants,
• Tobacco or other products with nicotine,
• Alcohol or other sedatives,
• Certain asthma medicines and some allergy and cold medicines, and
• Medicines called beta blockers, which are used to treat heart conditions.

Primary insomnia isn't due to another medical or emotional condition, and it typically occurs for periods of at least 1 month. Whether some people are born with a greater chance of having insomnia isn't known.

However, a number of life changes can trigger primary insomnia, including:

• Major or long-lasting stress and emotional upset, and
• Travel or other factors such as work schedules that disrupt your sleep routine.

Even after these causes go away, the insomnia might stay. It may continue because of habits formed to deal with the lack of sleep. These habits include taking naps, worrying about sleep, or going to bed early.

Who Is At Risk for Insomnia and What Are Its Signs and Symptoms?

Insomnia is a common health problem. One in 3 adults occasionally has insomnia. One in 10 adults has chronic, or long-term, insomnia. Insomnia affects women more often than men, and it can occur at any age. However, older adults are more likely to have insomnia than younger people.

People especially prone to insomnia include those who are depressed or under a lot of physical or emotional stress. People who work at night or have frequent major shifts in their work hours also are at risk for insomnia. Additionally, people who travel long distances with time changes may be prone to this condition.

The main symptom of insomnia is trouble falling asleep, staying asleep, or both—which leads to lack of sleep. The lack of sleep can cause others symptoms, such as:

• Waking up feeling tired or not well rested,
• Feeling tired or very sleepy during the day,
• Having trouble focusing on tasks, and
• Feeling anxious, depressed, or irritable.

How Is Insomnia Diagnosed?

Your doctor will usually diagnose insomnia based on your medical history, sleep history, a physical exam, and a sleep study if the cause of your insomnia is unclear.

To find out whether there's a medical cause for your insomnia, your doctor will ask about your medical history. He or she may ask:

• Whether you have any new or ongoing health problems,
• Whether you have painful injuries or health conditions, such as arthritis, and
• Whether you take any medicines, either over-the-counter or prescription.

Your doctor also may ask questions aimed at finding whether work or leisure habits are causing your insomnia. He or she may ask about your work and exercise routines; your use of caffeine, tobacco, or alcohol; and how often you travel.

Your doctor also may ask whether you have any new or ongoing work, personal problems, or other stresses in your life. In addition, you may be asked whether you have other family members with sleep problems.

To get a better sense of your sleep problem, your doctor will ask you details about your sleep habits, including:

• How often you have trouble sleeping and how long the problem has persisted,
• When you go to bed and get up on workdays and days off,
• How long it takes you to fall asleep, how often you wake up at night, and how long it takes to fall back asleep,
• Whether you snore loudly and frequently, or wake up gasping or feeling out of breath,
• How refreshed you feel when you wake up, and how tired you feel during the day, and
• How often you doze off or have trouble staying awake during routine tasks, especially driving.

Your doctor might ask you to keep a sleep diary for 1 to 2 weeks so you can answer these questions easily. You may want to ask your bed partner to help with the sleep diary.

To see what could be causing or worsening your insomnia, your doctor will also ask you:

• Whether you worry about falling asleep, staying asleep, or getting enough sleep,
• What you eat or drink, and whether you take medicines before going to bed,
• What routine you follow before going to bed,
• What the noise level, lighting, and temperature are like where you sleep, and
• What distractions, such as a TV or computer, are in your bedroom.

After asking about your medical and sleep histories, your doctor will do a physical exam to rule out other medical problems that might cause insomnia. You may also need blood tests to check for thyroid problems or other conditions that can cause sleep problems.

Your doctor may recommend a polysomnogram. This is a sleep study that records your breathing, movements, heart function, and brain activity during sleep. For this study, you sleep overnight at a special sleep center.

Your doctor usually will recommend a sleep study if you have signs of another sleep disorder, such as sleep apnea or restless legs syndrome.

How Is Insomnia Treated?

Making lifestyle changes that make it easier to fall asleep and/or stay asleep can often relieve insomnia.

For example, you should avoid substances that make insomnia worse.

Caffeine, tobacco, and other stimulants taken too close to bedtime can disrupt sleep, and the effects of caffeine can take as long as 8 hours to wear off. Certain over-the-counter and prescription medicines also can disrupt sleep—for example, some cold and allergy medicines.

Don't drink alcohol before bedtime. An alcoholic drink may make it easier for you to fall asleep, but alcohol triggers sleep that tends to be lighter than normal and makes it more likely that you will wake up during the night.

Exercising, eating a heavy meal, or drinking a lot shortly before bedtime also can worsen insomnia.

Good bedtime habits can relieve insomnia and make it easier to fall asleep and stay asleep.

Follow a routine that helps you wind down and relax before bed, such as reading a book, listening to soothing music, or taking a hot bath.

Make sure your bedroom is a comfortable temperature, dark, and quiet enough for sleep. Avoid bright lighting and minimize possible sleep distractions, such as a TV, computer, or pet.

Go to sleep around the same time each night and wake up around the same time each morning, even on weekends. If possible, avoid night shifts or alternating schedules at work and other causes of irregular sleep schedules.

Several medicines also can help relieve insomnia and reestablish a regular sleep schedule.

Doctors sometimes prescribe sleep-inducing medicine for 1 to 2 weeks to help establish a regular sleep schedule. Insomnia medicines help you fall asleep, but may leave you feeling unrefreshed or groggy in the morning. Because of this, you should be careful if you have to get up before getting a full night's sleep of 7 to 8 hours while taking these medicines.

Medicines also are available to treat symptoms of excessive sleepiness if your insomnia is the result of shift work or alternating work schedules. You should discuss your situation with your doctor to determine whether these medicines, together with improving sleep habits, can help you overcome insomnia.

The Food and Drug Administration, or FDA, hasn't approved all insomnia medicines for continuous, long-term use. Your doctor can help you understand the benefits and potential problems if medicines will be needed for long periods.

Some people use natural remedies to treat their insomnia. These remedies include melatonin and L-tryptophan supplements and valerian teas or extracts. The FDA doesn't regulate these over-the-counter treatments. This means that their dose and purity can vary from product to product. Their safety and effectiveness is not well understood.

For longer lasting insomnia, a type of counseling called cognitive-behavioral therapy can help relieve the anxiety linked to your sleep problem.

Cognitive-behavioral therapy for insomnia targets the thoughts and actions that can disrupt sleep. Besides encouraging good sleep habits, this type of therapy may use several methods to relieve sleep anxieties.

Relaxation training and biofeedback are used at bedtime to reduce anxiety. These strategies help you better control your breathing, heart rate, muscles, and mood.

Another method involves replacing worries about not being able to fall asleep with more positive thinking that links being in bed with being asleep. This method also teaches you what to do if you're unable to fall asleep within a reasonable time.

As part of the therapy, you may talk with a therapist individually or in group sessions to help you consider your thoughts and feelings about sleep. This method may encourage you to describe thoughts racing through your mind in terms of how they look, feel, and sound. The goal is for your mind to settle down and stop racing.

Another method is to limit the time you spend in bed while awake. This involves setting a sleep schedule and, at first, limiting your time in bed to the time you're usually asleep. For example, if you usually only sleep 4 hours a night, you will only spend 4 hours in bed. At first, this schedule may make you even more tired because some of the allotted time in bed will be taken up by difficulty sleeping. The tiredness that results from this method is intended to help you get to sleep more quickly. Gradually, you increase your time in bed until you get a full night of sleep.

For success with cognitive-behavioral therapy, you may need to see a therapist who is skilled in this approach weekly over 2 to 3 months. This therapy is as effective as prescription medicine for many types of chronic insomnia. It also may provide better long-term relief than medicine alone.

Links to Other Information About Insomnia

For more information about insomnia and other sleep disorders, including "Your Guide to Healthy Sleep" go to the NHLBI Web site at www.nhlbi.nih.gov.

You can download or order copies of NHLBI publications from the Web site. To speak with a health information specialist or order print copies of publications, call the NHLBI Health Information Center at 301–592–8573.