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Definition
Insomnia is a sleep disorder characterised as the subjective experience of difficulty falling and/or staying asleep (Benjamins, 2017). It is divided into short-term (acute) insomnia and long-term (chronic) insomnia (NHS, 2021). Insomnia can be further categorised into:
Primary insomnia
When the insomnia is not directly related to a medical, psychological, or environmental cause.
Secondary insomnia
The insomnia is a direct result or symptom of another factor, such as a health condition, medication, pain, or depression (Lichstein et al, 2001). For example, around 75% of depressed patients report insomnia symptoms (Nutt et al, 2008), and it is also prevalent in people with anxiety disorders (Staner, 2003). Therefore, the presence of insomnia can provide insight into other underlying issues that may require further attention.
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Symptoms
An individual may suffer from insomnia if they are experiencing the following symptoms:
- trouble falling or staying asleep
- waking up several times during the night
- lying awake at night
- waking up early and finding it difficult to go back to sleep
- finding it hard to nap during the day despite feeling tired
- irritability or disturbed mood
- difficulty in concentrating during the day
- unrefreshing and rough sleep (Mayo Clinic 2016; NHS, 2021)
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Aetiology
Spielman’s behavioural model of insomnia – also known as ‘the 3 Ps model’ suggests that there are three sets of factors that contribute to insomnia. These are predisposing, precipitating, and perpetuating factors (Spielman et al, 1987).
Predisposing factors
Factors that are out of the individual’s control. Examples include genetics and being prone to anxiety. These factors are usually not enough to cause insomnia on their own.
Precipitating factors
Situations or factors that may trigger short-term insomnia, or sleep disruption. For example, an upcoming exam, a developing illness such as flu, shift work, or a traumatic event. Once the precipitating factor is resolved, the individual should return to their normal sleep pattern. However, this is not the case with chronic insomnia.
Perpetuating factors
The unhelpful habits and thought patterns an individual may start to develop to compensate for and cope with the fatigue and sleeplessness.
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Diagnosis
A formal diagnosis of chronic insomnia is based on self-reported symptoms alone. No objective tests such as a sleep study, also known as polysomnogram, can diagnose insomnia. This is because information derived from polysomnographic data do not accurately reflect the sleep problems reported by many patients (Krystal et al, 2019). To receive a diagnosis of chronic insomnia, an individual must present with some of the symptoms described above (for example, trouble falling asleep and/or unrefreshing sleep) for at least 3 months (Santos-Longhurst, 2018). Sleep difficulties without functional impairment do not meet the diagnostic criteria for insomnia (National Institute for Health and Care Excellence (NICE), 2022).
A sleep diary may help assess sleep difficulties. It should be kept for 2 weeks and record:
- the time of going to bed and getting up
- the time taken to get to sleep and the number and duration of episodes waking through the night
- episodes of tiredness
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Management
Self-hygiene
If insomnia is mild, the individual can try self-promoting sleep strategies to help alleviate the sleep issue. Sleep hygiene practices that may be helpful include:
- Maintaining a comfortable sleep environment – the room should be not too hot, cold, noisy or bright (NICE, 2022).
- Establishing a consistent sleep routine – this involves going to bed and waking up at the same time every day, including weekends. By adhering to a sleep schedule, the body’s internal clock becomes accustomed to resting at a specific time every day. It is advisable to maintain this fixed wake-up time, even if the individual has not slept well during the night.
- Avoiding electronics – if possible, the individual should try to avoid using any electronic devices approximately 30 minutes before going to bed. Smartphones, tablets, and laptops can cause mental stimulation and disrupt the natural production of melatonin, the hormone that regulates your sleep cycle,
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Resources
Benjamins JS, Migliorati F, Dekker K et al. Insomnia heterogeneity: Characteristics to consider for data-driven multivariate subtyping. Sleep Med Rev. 2017;36:71-81. https://doi.org/10.1016/j.smrv.2016.10.005
Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. World Psychiatry. 2019;18(3):337-352. https://doi.org/10.1002/wps.20674
Lichstein KL, Durrence HH, Bayen UJ, Riedel BW. Primary versus secondary insomnia in older adults: subjective sleep and daytime functioning. Psychol Aging. 2001;16(2):264-71. https://doi.org/10.1037//0882-7974.16.2.264
Mayo Clinic. Insomnia. 2016. https://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167 (accessed 22 February 2023)
National Institute for Health and Care Excellence. Insomnia. 2022. https://cks.nice.org.uk/topics/insomnia/ (accessed 22 February 2023)
NHS. Insomnia.. 2021. https://www.nhs.uk/conditions/insomnia/ (accessed 22 February 2023)
Newsom, R. Cognitive Behavioral Therapy for Insomnia (CBT-I). 2023. https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia (accessed 22 February 2023)
Nutt D, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci. 2008;10(3):329-36. https://doi.org/10.31887/DCNS.2008.10.3/dnutt
Staner L. Sleep and anxiety disorders. Dialogues Clin Neurosci. 2003;5(3):249-58. https://doi.org/10.31887/DCNS.2003.5.3/lstaner
Santos-Longhurst A. What is chronic insomnia and how is it treated? 2018.
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