What is Insomnia? – Causes, Symptoms & Treatments

What is Insomnia?

Insomnia isn’t defined by a specific number of hours of sleep, since needs vary. Instead, it’s characterized by:

Difficulty falling asleep

Taking a long time, often more than 30 minutes, to drift off

Difficulty staying asleep

Waking up frequently during the night or too early in the morning and not being able to fall back asleep

Non-restorative sleep

Even if you log enough hours, the sleep is light or poor quality, so you still feel unrefreshed

For it to be considered insomnia disorder:

• These issues happen at least 3 nights per week, and
• Have been going on for at least 3 months​ (for chronic insomnia; short-term insomnia can last less time, often tied to a stressor).
• And very importantly, it causes daytime problems such as fatigue, sleepiness, poor concentration, irritability, or reduced performance at work/school

Insomnia can occur on its own (primary insomnia), or be secondary to another cause (like pain, medication, anxiety, etc.). It can also be categorized by duration:

Primary Insomnia

Insomnia that occurs independently and is not directly caused by another health condition, medication, or substance. It stands alone as a disorder.

Secondary Insomnia

Insomnia caused by another condition such as chronic pain, medication side effects, mental health disorders, or substance use. Treating the root cause often improves sleep.

Acute Insomnia

Short-term insomnia that lasts a few days to a few weeks, typically triggered by stress, illness, travel, or life events. It often resolves on its own when the stressor fades.

Chronic Insomnia

Long-term insomnia lasting at least 3 months. It can be persistent or episodic and often results from multiple reinforcing factors like stress, poor sleep habits, or conditioned arousal.

In insomnia, people typically have adequate opportunity to sleep (unlike say, new parents or overworked individuals who just can’t allocate enough hours). But when they lie in bed, they just cannot sleep well. This can create a lot of frustration and anxiety around bedtime, which can actually worsen the insomnia (a vicious cycle).

It’s worth noting that insomnia is different from occasional sleeplessness or short sleep due to voluntary behavior. True insomnia is more involuntary – you want to sleep but your body or mind won’t cooperate.

Causes of Insomnia

Insomnia often has multiple contributing factors. Here are some common causes and risk factors:

Stress and Anxiety

Temporary stress (work deadline, financial worry, relationship issues) is a major cause of short-term insomnia. Your mind races at night, preventing relaxation. Chronic anxiety disorders can cause persistent insomnia; the brain is in a heightened state of worry or hyperarousal, which is incompatible with sleep.

Depression and other Mental Health Conditions

Depression can cause insomnia (and conversely, long-term insomnia can increase depression risk). With depression, people often have early morning awakenings or difficulty falling asleep due to ruminating thoughts. PTSD (post-traumatic stress) commonly leads to nightmares and insomnia. Bipolar disorder, ADHD, and others can also disrupt sleep.

Poor Sleep Habits (Poor Sleep Hygiene)

Irregular sleep schedules, frequent naps, stimulating activities before bed, using the bed for work/TV, caffeine or heavy meals late in the day, and too much screen time at night can all promote insomnia. Basically, behaviors that conflict with the natural sleep-wake cycle can train your body to resist sleep at bedtime.

Medications and Substances

Certain medications can cause insomnia as a side effect. Examples: some antidepressants, corticosteroids, decongestants, stimulants for ADHD, blood pressure medications, etc.. Also, substances like nicotine (a stimulant) and caffeine are obvious culprits if used too close to bedtime. Alcohol can make you drowsy initially but leads to fragmented sleep and early waking as it metabolizes​.

Environmental Disruptions

A sleeping environment that is noisy, too bright, too hot/cold, or otherwise uncomfortable can cause insomnia. Also, frequent disturbances (like a snoring partner, or needing to tend a baby) can lead to an insomnia pattern even when those disturbances aren’t present.

Shift Work or Schedule Changes

If you do shift work (night shifts, rotating shifts) your circadian rhythm can be chronically misaligned, leading to insomnia when you try to sleep during “normal” times​. Jet lag from traveling across time zones similarly causes temporary insomnia until your body adjusts.

Chronic Pain or Medical Conditions

Any condition that causes pain or discomfort at night (arthritis, back pain, fibromyalgia, acid reflux, etc.) can make it hard to sleep. Neurological conditions (Parkinson’s, Alzheimer’s) often disrupt sleep architecture . Also, disorders like hyperthyroidism can cause a general revved-up metabolism that interferes with sleep.

Other Sleep Disorders

Sometimes what seems like insomnia is due to another undiagnosed sleep disorder. For example, restless legs syndrome causes an irresistible urge to move the legs at night, keeping you awake. Sleep apnea causes breathing pauses and awakenings (the person may not recall all awakenings, but they fragment sleep leading to insomnia or unrefreshing sleep). Treating the underlying sleep disorder often improves the insomnia.

Age-related changes

As people get older, sleep often becomes lighter and more fragmented, and insomnia becomes more common. This can be due to changes in circadian rhythm, medical illnesses, or increased medication use in older age.

Hormonal Factors

Hormone fluctuations can trigger insomnia. Many women experience insomnia during pregnancy (especially third trimester discomfort or first trimester hormonal changes) and menopause (hot flashes and hormone changes at midlife often disrupt sleep). PMS or menstrual cycles can also cause some women to have a few nights of insomnia each month.

Often, insomnia starts due to a specific trigger (stress, travel, etc.), and then persists beyond that trigger because behaviors and thoughts around sleep change. For instance, someone has stress and can’t sleep for a week. Then they start to get anxious at bedtime anticipating not sleeping, maybe start spending excessive time in bed hoping to catch up, and soon they have a conditioned insomnia – even if the original stress resolved. This conditioned or learned aspect of insomnia is key in chronic cases.

Symptoms of Insomnia

The obvious symptoms are the nighttime sleep difficulties:

• Lying awake for a long time trying to fall asleep.
• Waking up in the middle of the night (and staying awake for 20+ minutes, often much longer).
• Waking up too early, like at 4 AM, and not being able to go back to sleep, even though you still feel tired.
• Sleep that is light or restless. Some describe it as “tossing and turning” all night, not getting into deep sleep.
• These occur even when you have a suitable sleep environment and no outside disturbances – meaning, it’s an internal issue.

Daytime Symptoms of Insomnia

• Fatigue or sleepiness during the day: (Interestingly, not everyone with insomnia reports feeling sleepy – some just feel tired but “wired” because their stress hormones are up. But many do feel very run-down.)
• Cognitive impairment: trouble concentrating, forgetfulness, feeling like your mind is foggy.
• Mood disturbances: irritability, anxiety, depression, or low motivation. Chronic insomnia is a risk factor for developing depression.
• Behavioral issues: in kids, insomnia may present as behavioral problems or hyperactivity (sometimes lack of sleep in children looks like over-activity rather than sluggishness).
• Lack of energy or motivation: simple tasks feel harder because you’re running on little sleep.
• Errors or accidents: you might make more mistakes at work, or have minor accidents due to tiredness.

Often people with insomnia start to dread bedtime because they associate it with frustration and sleeplessness. This can cause anxiety or even panic as evening approaches – a hallmark of chronic insomnia is this conditioned arousal at night.

Physical symptoms can include headaches or stomach issues from the stress and exhaustion. Insomniacs might also become preoccupied with sleep, clock-watching, or trying all sorts of things to sleep (sometimes rebounding between remedies, which can itself create unpredictability).

It’s important to differentiate insomnia from just short sleep. Some people naturally function okay on, say, 6 hours. They might not have “insomnia” if that 6 hours is continuous and they feel fine. Insomnia specifically is the struggle to get the sleep despite trying, plus not feeling okay during the day.

Diagnosis

If insomnia is affecting you, a doctor may evaluate it by:

• Taking a history: asking about your sleep patterns, routines, stresses, medical history, substance use, etc. You may be asked to keep a sleep diary for a week or two, logging bedtimes, wake times, awakenings, and how you feel​. This helps see patterns.
• Sometimes using questionnaires (like the Insomnia Severity Index) to gauge how bad it is.
• Ruling out other causes: They’ll consider if symptoms suggest sleep apnea (do you snore, gasp?), restless legs, etc. They might also check for thyroid issues, chronic pain, or mental health concerns if not already diagnosed.
• Typically insomnia is diagnosed clinically (no test “proves” insomnia). A sleep study is not usually needed unless another sleep disorder is suspected. However, if initial treatments fail, a sleep study might be done to ensure nothing like apnea is hidden.
• Chronic insomnia is often a diagnosis of exclusion – meaning, they ensure no other primary cause explains it, so it’s either its own disorder or co-morbid with other conditions.

Treatments for Insomnia

The good news is, insomnia is treatable. Both non-medication and medication approaches can help, with a strong emphasis these days on non-drug therapy as the first-line for chronic insomnia.

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is considered the gold standard treatment for chronic insomnia​. It addresses the thoughts and behaviors that sustain insomnia. CBT-I is typically administered by a trained therapist over about 4-8 sessions (can be group or one-on-one, and there are also online courses/apps that guide through CBT-I techniques). Key components include:

Sleep Hygiene Education:

Going over basics like maintaining a consistent schedule, limiting caffeine/alcohol, making the bedroom sleep-friendly, exercising (but not late at night), etc. (Though improving sleep hygiene alone may not fix chronic insomnia, it’s a foundation.)

Stimulus Control:

This technique aims to break the negative association between bed and wakefulness​. It includes rules like: go to bed only when sleepy (not just because it’s 10 PM), use the bed only for sleep and intimacy (no TV, no work, no lying awake stressing), if you can’t sleep after ~20 minutes, get up and do something relaxing in dim light until you feel sleepy, then return to bed. Over time, this retrains your brain to link bed with quickly falling asleep.

Sleep Restriction (or Sleep Consolidation):

This sounds counterintuitive but is very effective. It involves initially limiting the time you spend in bed to roughly the amount you’re actually sleeping (but no less than ~5 hours)​. For example, if you currently stay in bed 8 hours but only sleep 5, we might restrict you to 5.5 hours in bed (e.g., midnight to 5:30 AM). This builds sleep pressure and usually causes a bit of sleep deprivation, which then makes you fall asleep faster and sleep more solidly. As sleep efficiency improves, you gradually increase time in bed until optimal. This method should be done with guidance, but it’s very effective at resetting the body’s expectations and can break the insomnia cycle.

Cognitive Techniques:

Addressing anxious or negative thoughts about sleep. People with insomnia often have thoughts like “I’ll never sleep, I won’t be able to function tomorrow, I might go crazy without sleep.” CBT-I helps challenge and reframe these. Relaxation of the belief that “I must get 8 hours or else” can relieve performance pressure that contributes to insomnia. Techniques include worry time earlier in the day (set aside time to write down worries so they don’t flood you at night), and if you find yourself worrying in bed, remind yourself that even resting quietly has benefits and catastrophizing doesn’t help.

Relaxation Techniques:

Many with insomnia benefit from learning relaxation skills: deep breathing, progressive muscle relaxation, meditation, or listening to calming audio. These help reduce arousal at night.

Paradoxical intention:

Sometimes therapists will even advise a patient to try to stay awake as long as possible (paradoxically removing the pressure to sleep, which ironically often makes them feel sleepier).

CBT-I has a high success rate and long-lasting benefits, typically superior to medication in the long run​. It does require active participation and some discipline.

2. Medications and Supplements

For short-term insomnia (like acute stress-related), or if CBT-I is not available or fully effective, medications can play a role. However, they are generally recommended at the lowest effective dose and shortest duration needed, due to concerns of dependency or side effects.

Prescription sleeping pills:

These include the “benzodiazepine” sedatives (like temazepam) and the newer “Z-drugs” (like zolpidem/Ambien, eszopiclone/Lunesta)​. They can help you fall asleep faster or stay asleep longer. They do work, but they carry risks: next-day drowsiness, cognitive impairment, sleep-walking behaviors in some cases (especially Ambien), and potential for tolerance (needing higher doses) or dependency. Generally used for short periods (a few weeks). They’re not meant for indefinite nightly use in most cases.

Orexin receptor antagonists:

A newer class (e.g., suvorexant/Belsomra) that targets the wakefulness neurotransmitter orexin​. These help turn off wake signals. Some find them helpful, and they may have less risk of dependency than benzos/Z-drugs, but can still cause next-day sedation in some.

Melatonin agonists:

Ramelteon is a prescription that mimics melatonin to help with sleep onset. It’s not habit-forming and can be useful if the main issue is falling asleep, particularly for people with a circadian rhythm issue.

Over-the-counter (OTC) aids:

Common ones are antihistamines like diphenhydramine (Benadryl, found in Tylenol PM, etc.) or doxylamine. These cause drowsiness. They’re fine for occasional use, but side effects can be dry mouth, urinary retention (especially in older adults), and morning grogginess. grogginess. The body also builds tolerance to the sedative effect in about a week, so they stop working well.

Melatonin supplement:

Available OTC, it can help some people, especially for circadian-related insomnia or mild sleep onset issues. Typically 0.5 to 5 mg taken an hour before bed. It’s generally safe if used short-term; long-term effects aren’t fully clear but it’s considered low risk. It can be great for jet lag or shift workers adjusting schedule.

Herbal remedies:

Many try valerian root, chamomile, lavender, or other herbal supplements. Evidence is mixed or limited. Some people swear by them, others find no benefit. They are relatively safe (valerian at high doses can affect liver enzymes though, so caution).

Note on alcohol:

While some use alcohol to self-medicate insomnia, it’s not advised. It may knock you out initially, but as mentioned, it fragments REM sleep and often causes a rebound awakening in the second half of the night​, plus can lead to dependency.

Often for chronic insomnia, a combined approach works well: CBT-I techniques to address root behaviors and thoughts, plus possibly a short-term medication to get over the hump if needed. Once the CBT-I starts to work, medication can be tapered off.

3. Addressing Underlying Causes

If insomnia is secondary to something else, obviously, treating the underlying condition is key:

• Manage chronic pain with appropriate pain control (medications, physical therapy, etc.).
• Treat acid reflux (e.g., don’t eat late, use an acid reducer if needed).
• Optimize management of depression or anxiety (therapy, medications) as those conditions improve, sleep often improves.
• Diagnose and treat other sleep disorders like apnea (CPAP machine, oral appliance, etc.) or restless legs (iron supplements or medication if needed).
• For menopausal women with severe hot flashes, treating those (like hormone therapy or other meds) might relieve the night awakenings.
• If medications you need are causing insomnia, talk to your doctor about adjusting dose or timing (e.g., maybe take that stimulating med in the morning instead of at night).

4. Lifestyle and Home Strategies

Beyond formal CBT-I, some tips for self-care:

• Keep a regular sleep schedule as much as possible (even on weekends, try not to vary wake time by more than an hour or so).
• Get daylight exposure in the morning and stay active during the day. This strengthens circadian cues so you’re more likely to be sleepy at night​.
• Develop a calming pre-bed ritual: gentle stretches, reading (not on a bright screen), or taking a warm bath (as the body cools after a bath, it can induce sleepiness).
• Avoid long or late naps (if you must nap, do a brief 20 minutes before 3 PM).
• If you find yourself worrying a lot at night, practice writing down your worries or to-do list a couple hours before bed to get them out of your head. Then remind yourself that you’ve set those aside for now.
• Some people find using a sleep mask or earplugs helpful if light or noise are issues.
• Exercise regularly (at least 20-30 minutes on most days) can significantly improve sleep quality, but do it at least 3-4 hours before bed if vigorous, as exercising right before bed can be alerting for some​.

5. When to Seek Help

If you’ve had persistent insomnia for more than a few weeks and it’s affecting your daytime life, it’s wise to seek help from a healthcare professional. They can help identify if it’s primary insomnia or due to another cause, and guide treatment. Don’t suffer endlessly – insomnia can often be effectively treated, which can greatly improve your quality of life.