Insomnia Podcast Transcript

Welcome to the National Heart, Lung, and Blood Institute podcast on insomnia. This podcast will discuss what insomnia is and its causes, risk factors, and signs and symptoms. 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 condition in which you have trouble falling or staying asleep. This condition can range from 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.

Some people who have insomnia may have trouble falling asleep. Other people may fall asleep easily but wake up too soon. Others may have trouble with both falling asleep and staying asleep.

As a result, insomnia may cause you to get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up. The condition also can cause excessive daytime sleepiness and a lack of energy. It can make you feel anxious, depressed, or irritable.

You may have trouble focusing on tasks, paying attention, learning, and remembering. This can prevent you from doing your best at work or school.

Insomnia also can cause other serious problems. For example, you may feel drowsy while driving, which could lead to an accident.

There are two types of insomnia. The most common type is called secondary or comorbid insomnia. This type of insomnia is a symptom or side effect of some other problem.

More than 8 out of 10 people who have insomnia are believed to have secondary insomnia. Certain medical conditions, medicines, sleep disorders, and substances can cause secondary insomnia.

In contrast, primary insomnia isn't due to a medical problem, medicines, or other substances. It is its own disorder. A number of life changes can trigger primary insomnia, including long-lasting stress and emotional upset.

Secondary insomnia often resolves or improves without treatment if you can stop its cause—especially if you can correct the problem soon after it starts. For example, if caffeine is causing your insomnia, stopping or limiting your intake of the substance may cause your insomnia to go away.

Lifestyle changes, including better sleep habits, often help relieve acute insomnia. For chronic insomnia, your doctor may recommend a type of counseling called cognitive-behavioral therapy or medicines.

What Causes Insomnia?

There are two types of insomnia—secondary and primary. Secondary insomnia is the symptom or side effect of another problem. This type of insomnia often is a symptom of an emotional, neurological, or other medical or sleep disorder.

Emotional disorders that can cause insomnia include depression, anxiety, and posttraumatic stress disorder. Alzheimer's disease and Parkinson's disease are examples of common neurological disorders that can cause insomnia.

A number of other conditions also can cause insomnia, such as:

• Conditions that cause chronic pain, such as arthritis and headache disorders,
• Conditions that make it hard to breathe, such as asthma and heart failure,
• An overactive thyroid,
• Gastrointestinal disorders, such as heartburn,
• Stroke,
• Sleep disorders, such as restless legs syndrome and sleep-related breathing problems, and
• Menopause and hot flashes

Secondary insomnia also may be a side effect of certain medicines. For example, certain asthma medicines, such as theophylline, and some allergy and cold medicines can cause insomnia. Beta blockers also may cause the condition. These medicines are used to treat heart conditions.

Commonly used substances also may cause insomnia. Examples include caffeine and other stimulants, tobacco or other nicotine products, and alcohol or other sedatives.

In contrast, primary insomnia isn't a symptom or side effect of another medical condition or substance. This type of insomnia usually occurs for periods of at least 1 month.

A number of life changes can trigger primary insomnia. It may be due to major or long-lasting stress or emotional upset. Travel or other factors, such as work schedules that disrupt your sleep routine, also may trigger primary insomnia.

Even if these issues are resolved, the insomnia may not go away. Trouble sleeping may persist because of habits formed to deal with the lack of sleep. These habits may include taking naps, worrying about sleep, and going to bed early.

Researchers continue to try to find out whether some people are born with a greater chance of having primary insomnia.

Who Is At Risk for Insomnia?

Insomnia is a common disorder. One in 3 adults has insomnia sometimes. One in 10 adults has chronic insomnia.

Insomnia affects women more often than men. The condition can occur at any age, but older adults are more likely to have insomnia than younger people.

People who may be at higher risk for insomnia include those who:

• Have a lot of stress,
• Are depressed or who have other emotional distress, such as divorce or death of a spouse,
• Have lower incomes,
• Work at night or have frequent major shifts in their work hours,
• Travel long distances with time changes,
• Have certain medical conditions or sleep disorders that can disrupt sleep, or
• Have an inactive lifestyle.

Young and middle-aged African Americans also may be at increased risk for insomnia. Research shows that, compared to Whites, it takes African Americans longer to fall asleep. They also have lighter sleep, don't sleep as well, and take more naps. Sleep-related breathing problems also are more common among African Americans.

What Are the Signs and Symptoms of Insomnia?

The main symptom of insomnia is trouble falling and/or staying asleep, which leads to lack of sleep. If you have insomnia, you may:

• Lie awake for a long time before you fall asleep,
• Sleep for only short periods,
• Be awake for much of the night,
• Feel as if you haven't slept at all, and/or
• Wake up too early.

The lack of sleep also can cause other symptoms. You may wake up feeling tired or not well-rested, and you may feel tired during the day. You also may have trouble focusing on tasks and feel anxious, depressed, or irritable.

Insomnia may affect your daily activities and cause serious problems. For example, you may feel drowsy while driving. Driving while sleepy leads to more than 100,000 car crashes each year. In older women, research shows that insomnia raises the risk of falling.

If insomnia is affecting your daily activities, see your doctor. Treatment may help you avoid symptoms and problems related to the condition. Also, poor sleep may be a sign of other health problems. Finding and treating those problems could improve both your health and your sleep.

How Is Insomnia Diagnosed?

Usually, your doctor will diagnose insomnia based on your medical and sleep histories and a physical exam. He or she also may recommend a sleep study. For example, you may have a sleep study if the cause of your insomnia is unclear.

To find out what's causing your insomnia, your doctor may ask whether you:

• Have any new or ongoing health problems,
• Have painful injuries or health conditions, such as arthritis,
• Take any medicines, either over-the-counter or prescription,
• Have symptoms or a history of depression, anxiety, or psychosis, or
• Are coping with any very stressful life events, such as divorce or death.

Your doctor also may ask questions about your work and leisure habits. For example, he or she may ask about your work and exercise routines; your use of caffeine, tobacco, and alcohol; and your long-distance travel history. Your answers may give clues about what's causing your insomnia.

Your doctor also may ask whether you have any new or ongoing work or personal problems or other stresses in your life. Also, he or she may ask whether you have other family members who have sleep problems.

To get a better sense of your sleep problem, your doctor also will ask you details about your sleep habits. Before your visit, think about how to describe your problems, including:

• How often you have trouble sleeping and how long you've had the problem,
• 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 often 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.

To find out what's causing or worsening your insomnia, your doctor also may 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.

To help your doctor, consider keeping a sleep diary for 1 or 2 weeks. Write down when you go to sleep, wake up, and take naps. For example, you might note: Went to bed at 10 a.m.; woke up at 3 a.m. and couldn’t fall back asleep; napped after work for 2 hours.

Also write down how much you sleep each night, as well as how sleepy you feel at various times during the day.

You can find a sample sleep diary in the National Heart, Lung, and Blood Institute's "Your Guide to Healthy Sleep," which you can find on the NHLBI Web site at www.nhlbi.nih.gov.

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

Your doctor may recommend a sleep study called a polysomnogram, or PSG, if he or she thinks an underlying sleep disorder is causing your insomnia.

A PSG usually is done while you stay overnight at a sleep center. A PSG records brain electrical activity, eye movements, heart rate, breathing, muscle activity, blood pressure, and blood oxygen levels.

How Is Insomnia Treated?

Lifestyle changes often can help relieve acute, or short-term, insomnia. These changes may make it easier to fall asleep and stay asleep.

If you have insomnia, avoid substances that make it worse, such as caffeine, tobacco, and other stimulants taken too close to bedtime. Their effects can last as long as 8 hours.

Certain over-the-counter and prescription medicines, such as some cold and allergy medicines, can disrupt sleep. Talk to your doctor about which medicines won’t disrupt your sleep.

Although an alcoholic drink before bedtime may make it easier for you to fall asleep, alcohol triggers sleep that tends to be lighter than normal. This makes it more likely that you will wake up during the night.

Try to adopt good bedtime habits that make it easier to fall asleep and stay asleep. Follow a routine that helps you wind down and relax before bed. For example, read a book, listen to soothing music, or take a hot bath.

Try to schedule your daily exercise at least 5 to 6 hours before going to bed. Don't eat heavy meals or drink a lot before bedtime.

Make your bedroom sleep-friendly. Avoid bright lighting while winding down. Try to limit possible distractions, such as a TV, computer, or pet. Make sure your bedroom is dark and quiet and the temperature is cool and comfortable.

Go to sleep around the same time each night and wake up around the same time each morning, even on weekends. If you can, avoid night shifts, alternating schedules, or other things that may disrupt your sleep schedule.

If you have chronic, or ongoing, insomnia, a type of counseling called cognitive-behavioral therapy, or CBT, can help relieve the anxiety linked to this condition.

CBT for insomnia targets the thoughts and actions that can disrupt sleep. This therapy encourages good sleep habits and uses several methods to relieve sleep anxiety.

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

CBT also works on replacing sleep anxiety 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.

CBT also may involve talking with a therapist one-on-one 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.

CBT also focuses on limiting the time you spend in bed while awake. This method involves setting a sleep schedule. At first, you will limit your total time in bed to the typical short length of time you’re usually asleep.

This schedule may make you even more tired because some of the allotted time in bed will be taken up by problems falling asleep. However, the resulting tiredness is intended to help you get to sleep more quickly. Over time, the length of time spent in bed is increased until you get a full night of sleep.

For success with CBT, you may need to see a therapist who is skilled in this approach weekly over 2 to 3 months. CBT works as well as prescription medicine for many people who have chronic insomnia. It also may provide better long-term relief than medicine alone.

For people who have insomnia and major depressive disorder, CBT combined with antidepression medicines has shown promise in relieving both conditions.

Several medicines also can help relieve insomnia and re-establish a regular sleep schedule. However, if your insomnia is the symptom or side effect of another problem, it's important to treat the underlying cause, if possible. Your doctor also may prescribe medicine to help treat your insomnia.

Many prescription medicines are used to treat insomnia. Some are meant for short-term use, while others are meant for longer use.

Talk to your doctor about the benefits and side effects of insomnia medicines. For instance, insomnia medicines can help you fall asleep, but some people may feel groggy in the morning after taking them.

Rare side effects may include sleep eating, sleep walking, or driving while asleep. If you have side effects from an insomnia medicine, or if it doesn’t work well, tell your doctor. He or she may prescribe a different medicine.

Some insomnia medicines may be habit forming. Talk to your doctor about the benefits and risks of insomnia medicines.

Some over-the-counter products claim to treat insomnia. These products include melatonin, L-tryptophan supplements, and valerian teas or extracts.

The Food and Drug Administration doesn't regulate "natural" products and some food supplements. Thus, the dose and purity of these products can vary. How well these products work and how safe they are isn't well understood.

Some over-the-counter products that contain antihistamines are marketed as sleep aids. Although these products may make you sleepy, talk to your doctor before taking them.

Antihistamines pose risks for some people. Also, these products may not offer the best treatment for your insomnia. Your doctor can advise you whether these products can benefit you.

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.