It’s a horrible feeling: You’re exhausted, lying in your bed and you can’t fall asleep. And this isn’t a one-off; it’s been happening more and more lately.
You might have the sleep disorder known as insomnia.
“Insomnia is difficulty starting sleep, staying asleep or an issue with the quality of sleep that leads to daytime impairment,” says UNC Health pulmonologist and sleep medicine physician Adnan Pervez, MD, who is medical director of the UNC Rex Sleep Disorders Center. “The daytime impairment—not feeling rested, difficulty focusing or concentrating or slowed motor skills—is key to making the diagnosis.”
If you feel tired during the day because you stayed up too late watching a movie or you have a newborn, that isn’t insomnia. But if you have the opportunity to sleep and aren’t able to, and you don’t feel rested, talk to your doctor.
Dr. Pervez explains potential causes and treatments for insomnia.
Causes of Insomnia
Insomnia can be acute (short-term) or chronic (long-term). Acute insomnia, maybe a week of poor sleep or a few nights here and there over several months, affects about one-third of the United States population. It can be caused by stress, new medication and life changes.
Chronic insomnia is typically defined as trouble falling or staying asleep more than three nights per week for longer than three months and is estimated to affect about 10 percent of the population.
A variety of medical conditions and mental health disorders such as Parkinson’s disease, Alzheimer’s disease, chronic pain, depression and anxiety can cause both types of insomnia. Other sleep disorders, including sleep apnea and restless legs syndrome, also can contribute.
Women may experience insomnia at certain parts of their menstrual cycles due to hormone shifts, and it’s common during pregnancy.
Aging also can cause insomnia. If you wake more frequently to use the bathroom at night, you might find it difficult to get back to sleep, and symptoms of menopause, including hot flashes and night sweats, can disrupt sleep. Your risk for sleep apnea increases with age.
Your sleeping environment could be the problem. If your bedroom is too noisy, bright or hot, or if your mattress is painful, it will be harder to fall asleep. Habits such as late-afternoon caffeine, vigorous evening workouts or scrolling social media before you turn out the light also make it harder to sleep.
Often, worry about insomnia makes insomnia worse.
“People experience distress or discomfort when they can’t sleep at night, so the process of trying to sleep can morph and take on a life of its own,” Dr. Pervez says. “Lying in bed and attempting to force yourself to sleep without success can worsen distress and anxiety around sleep, conditioning the brain to associate the bed with poor sleep.”
Diagnosing Insomnia
To diagnose insomnia, your provider will ask you a lot of questions. They’ll want to know how your sleeplessness occurs: Do you have trouble falling asleep, or are you waking up in the middle of the night? You’ll be asked about recent stressors and your sleep hygiene, and they will review your medical history, current health conditions and medications. If there are underlying medical or psychiatric problems, addressing those will be part of the treatment plan.
Your provider may ask you to keep a sleep diary, taking careful note of when you went to bed and when you woke up, as well as any nighttime wakings and activities that could impair sleep.
“A sleep diary is a way to pay careful attention night to night to better track sleep patterns and provides valuable insights,” Dr. Pervez says.
If you track your sleep with a wearable device, you can show the results to your provider but know that they aren’t always accurate, particularly in identifying deep sleep, Dr. Pervez says.
“There’s a relatively new phenomenon called orthosomnia, where there’s a perception, sometimes based on a wearable, that you’ve experienced less restful sleep than you actually did,” Dr. Pervez says.
There’s a test called actigraphy in which you wear a medical-grade device on your wrist to track sleep data such as movements and wakings in the night. Unfortunately, actigraphy is not covered by most insurance plans, which is why your doctor considers your full history, a sleep diary and some information from your wearable, like duration of sleep, when making the diagnosis and considering treatment.
Insomnia Treatment Options
Cognitive behavioral therapy for insomnia (CBT-I) is the primary treatment for insomnia. It uses the principles of cognitive behavioral therapy to change negative thoughts and behaviors around sleep and replace them with habits that improve sleep and create more positive associations with your bed.
“When you stay in bed and toss and turn when you can’t sleep, you’re building an association of distress,” Dr. Pervez says. “Leave the bedroom when you can’t sleep and go to another part of the house, where it’s not overly stimulating or bright. Read, listen to music, pray or meditate, and return to the bed when you’re ready for sleep.”
Another part of CBT-I is restricting the amount of time you’re in your bed.
“When people have poor sleep, they tend to stay in bed longer in the morning to sleep in, or they go to bed hours too early to try to catch up,” Dr. Pervez says. “Trying to compensate for poor sleep this way can affect the quality of sleep in the long run.”
Under the guidance of a therapist or doctor, you may be prescribed a certain number of hours you can be in your bed each night. You may be advised to set an alarm for a particular time in the morning and to avoid going to bed more than a specific number of hours prior to that. After a period of doing this consistently, your body learns how to sleep in that appropriate window.
You can talk with your therapist about anxiety related to your ability to sleep and learn how to use relaxation techniques. An important element of therapy is to address dysfunctional beliefs and attitudes about sleep. They can help improve your sleep hygiene and work on the lifestyle factors that might be keeping you awake, such as alcohol or difficulty putting down your phone.
Dr. Pervez says behavioral therapy is safer than any prescription or over-the-counter sleep medication, but that medication can be appropriate in some instances of both acute and chronic insomnia. When you’re taking a sleep medication, it’s important to use one that’s recommended or prescribed by your provider.
“Medications may cause dependence or side effects and, possibly, long-term problems with cognition and memory, but in some situations, you and your provider may decide that the benefits outweigh these concerns,” Dr. Pervez says. “Talk to your provider about safe medications for your situation and taking a low yet effective dose. Medications should always be combined with behavioral modification as well, for the most long-lasting benefits.”
Always tired? Talk to your doctor. If you need a doctor, find one near you.