Types of Insomnia

From verywellhealth.com 

Insomnia is a common sleep disorder that makes it hard to fall asleep and/or remain asleep. Insomnia prevents you from getting the amount and quality of sleep you need to function normally.

Without treatment, insomnia can affect daytime alertness. It can impact your ability to think, remember, and react. It can also affect your health and disease risk.

Not everyone who struggles with insomnia has the same issues. Different types of insomnia vary in their cause, the sleep problems associated with them, and how long they occur.

This article discusses the types of insomnia, their symptoms, and how the condition is diagnosed and treated.

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Types of Insomnia

All types of insomnia interfere with getting the amount and quality of sleep you need. The effect of insufficient sleep on your body is generally the same across all types of insomnia.

Common symptoms across all types of insomnia include:

• Taking a long time to fall asleep
• Having a cycle of sleep and wakefulness through the night
• Feeling that you didn't sleep when you awaken
• Having daytime fatigue or sleepiness
• Lacking motivation or energy
• Having problems paying attention, remembering, or concentrating
• Being unable to perform normally at work or school
• Being irritable and moody
• Making preventable errors or having accidents
• Being concerned about your lack of sleep
  
• Waking up too early in the morning

Understanding the variations of insomnia can help you identify the factors that may be causing your problem so you can work to correct them.

Acute vs. Chronic Insomnia

Insomnia can be classified by the amount of time the problem affects your life. It can be described as acute (short term) or chronic (long term). It can also occur for a period, stop, and then recur.

Acute insomnia involves problems falling asleep or staying asleep at least three days per week for a period of between one week and three months. It is usually linked to one of the following factors:

• Stress at home and/or work
• Stress in personal or professional relationships
• Physical injury
• Environmental changes caused by light, noise, or temperature
• Acute pain
• A traumatic event such as the loss of a loved one, divorce, or job loss
• Jet lag
• Temporary use or withdrawal of caffeine, alcohol, illegal drugs, or prescribed medications
• Shift work

Chronic insomnia involves being unable to fall asleep or stay asleep at least three days per week for a period of three months or longer. It may result when the stressors that cause acute insomnia aren't handled.

Chronic insomnia can also occur as a symptom or side effect of one of the following conditions:

• Chronic medical conditions like GERD (gastroesophageal reflux disease), heart disease, or thyroid problems
• Other sleep disorders like sleep apnoea or restless legs syndrome (RLS)
• Chronic mental health problems like depression, anxiety, or PTSD (post-traumatic stress disorder)
• Long-term use of certain medications or illegal drugs
• Long-term use of caffeine or alcohol 
• Lack of regular sleep habits

Primary vs. Secondary Insomnia

Insomnia can also be classified based on the condition's relationship to other issues.

Primary insomnia occurs when your inability to sleep isn't linked to a known cause. The fact that you can't sleep and/or remain asleep isn't due to a side effect of a medical condition, psychological issue, or medication.

Primary insomnia may occur due to unknown causes, though it can be linked to the effects of the following issues:

• Long-lasting stress
• Emotional distress
• Travel or jet lag
• Shift work

Secondary insomnia accounts for most cases of insomnia. It can be acute or chronic. Secondary insomnia occurs as a side effect or symptom of one of the following factors:

• Medical conditions
• Psychological conditions
• Sleep disorders
• Substances like caffeine, alcohol, or tobacco
• Prescription medications or illegal drugs

Onset vs. Maintenance Insomnia

Insomnia can be defined based on where it interferes with the natural sleep cycle. It can prevent you from falling asleep and staying asleep.

Onset insomnia affects your ability to fall asleep at the time you wish. It is usually linked with psychological or psychiatric issues. Onset insomnia can also be a symptom secondary to a medical condition or sleep disorder.

Onset insomnia is more common in younger than older adults. It can also occur when children become stressed by being alone before sleep.

People who have onset insomnia often have one of the following conditions, though others are possible:

• Psychophysiological insomnia (PPI)
• Obstructive sleep apnoea-hypopnea syndrome
• Periodic limb movements in sleep (PLMS)
  
• Delayed sleep phase syndrome
• Congestive heart failure 
• Restless legs syndrome

Maintenance insomnia is a condition that makes it difficult to maintain sleep after you've fallen asleep. It occurs more often in older adults since sleep cycles change with age.

How Sleep Changes As You Age

As you age, you spend more time in the lighter stages of sleep and less time in the deeper settings. This makes you more aware of environmental changes, such as noise. It also makes you more likely to react to physical changes, like arthritis or nocturia (nighttime urination), that occur while you sleep.

Other Types of Insomnia

Other types of insomnia include the following:

Behavioural Insomnia of Childhood

Some types of insomnia are more common in children. They occur when children associate certain behaviours with falling asleep. They include:

• Sleep-onset association insomnia occurs when children rely on actions, such as being rocked or held, to fall asleep. They become unable to sleep without the specific action.
• Limit-setting insomnia occurs when a child acts out before bedtime. They typically make repeated demands and refuse to go to sleep. This often occurs because they don't have a strict bedtime routine that is enforced nightly.

Idiopathic Insomnia

Idiopathic insomnia is a form of chronic insomnia. It occurs without any visible causes. It often begins in childhood and becomes a lifelong problem that occurs nightly.

Inadequate Sleep Hygiene 

Inadequate sleep hygiene is a sleep disorder that occurs when you have sleep habits that interfere with sleep. This problem can develop when you don't have a healthy bedtime routine to help you fall asleep naturally.

Paradoxical Insomnia

Paradoxical insomnia is a disorder in which you complain of getting poor sleep or not getting enough sleep, even though there is no evidence of a sleep problem.

Psychophysiological Insomnia

Psychophysiological insomnia is defined as having a state of heightened arousal, worry, and anxiety about sleep and sleeplessness. Instead of falling asleep, people focus on their sleep and are concerned about not getting enough of it.

Psychophysiological insomnia is considered a learned form of insomnia. It usually occurs when you can't sleep and then become overly concerned about getting enough sleep. Even though you may realize that your anxiety interferes with sleep, the worry increases as you remain awake.

Complications of Poor Sleep

Getting inadequate or poor sleep due to insomnia can have a dramatic impact on your physical and mental health. Without proper rest, your body and brain don't have a chance to repair themselves. Lack of sleep can impact your overall well-being.

Insomnia can increase your risk of the following complications:

• High blood pressure
• Coronary artery disease
• Cancer
• Diabetes
• Obesity
• Stroke
• Depression
• Injury to yourself or others in an accident as a result of impaired cognitive abilities

How Insomnia Is Diagnosed

Your healthcare provider may recommend that you see a sleep specialist if you complain of insomnia that doesn't improve with lifestyle changes. To determine the cause of your sleep problems, your healthcare provider or sleep specialist may do the following:

• Take your medical history, including medical conditions, medications, and sources of stress
• Take your sleep history, preferably from a sleep diary that you have kept to describe the type of sleep problem you're having, what it feels like, and how long it has occurred
• Perform a physical exam to find any physical causes for your insomnia
• Refer you for or perform a polysomnogram (sleep study) overnight in a sleep lab to monitor a sleep cycle

Treatment and Prevention

The type of treatment your healthcare provider recommends depends on the type of insomnia you have and the cause of the problem. The condition is usually resolved when the underlying medical or psychological cause is treated.

Research indicates that the best results are achieved by combining medical and nonmedical treatments rather than using one alone.

Common treatments for insomnia include:

• Cognitive-behavioural therapy (CBT, a type of talk therapy)
• Lifestyle changes
• Prescription medication to help you sleep
• Over-the-counter sleep aids that contain antihistamines or diphenhydramine
• Melatonin supplement (lab-made form of the hormone melatonin)

You can help prevent insomnia by taking these precautions:

• Avoid substances like caffeine, alcohol, and some medications that can prevent quality sleep.
• Follow the same sleep routine every night, including waking at the same time every day.
• Get out of bed if it takes too long to fall asleep, then try again 15 minutes later.
• Avoid napping.
• Sleep in a cool, dark room.
• Don't use electronics or your phone in the bedroom.
• Avoid eating, drinking, or exercising close to the time you want to fall asleep.
• Learn relaxation and deep breathing techniques to help you relax.
• Treat and maintain physical and psychological conditions.
  

Summary

Insomnia is a common sleep disorder. It can prevent falling asleep and staying asleep. There is more than one type of insomnia. Types differ by cause, how long they last, and how they affect you.

To treat insomnia, you must treat the cause of your sleep problems. Treatment can include cognitive behavioural therapy, medications, and lifestyle changes. Using both medical and nonmedical therapies can improve your sleep.

A sleep expert can help you find the treatment you need. Insomnia often improves or resolves when the primary cause is treated. This can help you enjoy the health and mental benefits of a good night's sleep.

A Word From Verywell

Living with any insomnia can affect your quality of life. Without enough sleep, it's normal to feel tired and moody throughout the day.

Chronic irritability can affect both personal and work relationships. It can also increase your risk of causing accidents as your thinking skills weaken without enough sleep.

The good news is that insomnia can often improve when you treat the cause of the problem. Consult your healthcare provider to get started on a plan to fix your sleep problems. The result can improve your health, relationships, and the way you feel.

FREQUENTLY ASKED QUESTIONS

• How much sleep does the average adult need?

  Individual sleep needs vary based on age, overall health, and genetics; the average adult needs seven to nine hours of sleep every night. Adults over age 65 may need less sleep, usually between seven and eight hours nightly.

• Do certain foods cause insomnia?

  The type of foods and drinks you consume can affect your ability to get quality sleep. Some foods can interfere with natural sleep patterns, leading to insomnia over time. Some foods that can affect your sleep include caffeine, black tea, sweets, white bread, nightshade vegetables, fast food and other highly processed foods, fried foods, and aged or cured foods.

• Can melatonin help you fall asleep?

  Studies indicate a link between melatonin and quality sleep. Results show that people who took melatonin fell asleep faster and improved their sleep efficiency. While melatonin provides modest benefits, it's best to consult your healthcare provider about the impact of melatonin on your insomnia.

https://www.verywellhealth.com/types-of-insomnia-5226021

I’m a sleep expert – here’s 3 surprising ways we help insomniacs sleep

From thesun.ie

By Vanessa Chalmers

A SLEEP expert has revealed the worst things you can do when you’ve got insomnia - and the surprising ways it’s really treated. 

Sleep physiologist Stephanie Romiszewski revealed the sleep disorder is often tackled in the wrong way. 

Around ten per cent fulfil the criteria for insomnia disorder, the National Institute for Health and Care Excellence (NICE) says.

Insomnia can last just a few days (transient), stretch into a few weeks (acute) or become chronic, lasting several months or even years.

How it’s tackled could impact how long it sticks - and it’s largely within your own control, Stephanie, who runs The Sleepyhead Clinic in Exeter, explains.

People try to go to bed earlier, take naps or pop sleeping pills in order to make up for lost hours.

But this may worsen symptoms by confusing the body even more, she says.

Instead, one of the ways experts fix the condition is to restrict bedtime in those with insomnia. 

Here's what you need to know...

How NOT to deal with insomnia 

Recognising you have insomnia might be frightening.

Stephanie told The Sun: “Unfortunately, insomnia has that label. And what comes along with that is this real fear and so it makes people do strange things.”

Stephanie says when people are worried they aren’t sleeping well enough, their first reaction is often to “alter their behaviour quite significantly”.

This can often cause more problems.

“Sleep is all about time," says Stephanie.

“If you start mucking about with the goalposts, by changing your wake time, and going to bed early… basically trying to manipulate sleep because you're worried you stopped sleeping, that's actually a way to make the sleep problem worse.”

In a similar vein, Stephanie warns against coping mechanisms that only increase the anxiety in your life.

Things like “sleeping pills, avoiding going to the gym, avoiding seeing your friends, moving away from the life that you want to live”.

“Suddenly you're a complete shell of your former self," she warns.

"Not only do you have a sleep problem, but you've got a huge anxiety problem."

This reaction to short-term insomnia may cement the condition in somebody’s life chronically. 

Once you realise insomnia is just a pattern, you have the capacity to change the pattern

Stephanie

"Why hasn't that sleep problem gone away? Well, it's not usually down to the original trigger anymore," says Stephanie.

“Once you've had it for longer than three months, it turns into a habitual problem, which means your brain is starting to see it as a pattern.

“It is actually because you’ve trained the brain into a new pattern with all the behaviour and coping mechanisms you thought were going to help.

“And so actually, once you realise insomnia is just a pattern, you have the capacity to change the pattern.”

What to do instead

Relax…

Stephanie says one of the first things to understand about insomnia is that it does not mean there is something genetically wrong with you, or there is any kind of chemical imbalance in the brain.

It can be tackled by changing beliefs and behaviours.

Most sleep problems are “entirely normal” and common.

And while the word insomnia may instil fear, meaning “no sleep” in Latin, you don’t need to take it quite so literally. 

“If people with insomnia were getting absolutely no sleep, they would be dead,” Stephanie says. 

“That is not what is actually happening with insomnia. This is the first point to make because people really get frightened. 

“They think something terrible is going to happen. But actually that’s not the case.”

Only one form of insomnia, called fatal familial insomnia, a genetic disorder, has the ability to kill over a few weeks - and it is incredibly rare.

How the experts treat insomnia

Treating insomnia is all about retraining the brain, and re-education on how sleep works, says Stephanie.

Restrict bed time

The first thing insomniacs should do is to stop spending so much time in bed, willing themselves to nod off. 

"A lot of people with insomnia will think, ‘I need to increase my time in bed to try to encourage sleep to come’," says Stephanie.

“But that doesn't come from any science that we know. You cannot fall asleep just by spending more time in the place where you used to sleep. 

“You've got to actually restrict your bedtime down.”

It sounds counterintuitive, but restricting the amount of time you spend in bed can help improve sleep quality.

Sleep quality is, experts argue, more important than sleep quantity.

It refers to how restful and useful your sleep is, as opposed to how long you spend in slumber. 

You cannot fall asleep just by spending more time in the place where you used to sleep

Stephanie

Restricting the time you spend in bed = no daytime napping, and no lie ins. This will help you create a sleep drive (AKA, a strong desire to sleep).

“After a while what you notice is your body actually gives you this wonderful, really good quality sleep. So suddenly you feel in control of your sleep again," says Stephanie.

“Once we've got that good quality, we add time [hours asleep].”

But as a patient with insomnia, you’ll have to drop the idea that eight hours of blissful sleep is either necessary, or achievable.

“We've got to help you understand what good sleep is, and that doesn't mean perfection. Sometimes you're going to have poor sleep,” admits Stephanie.

CBTi 

A therapist can provide cognitive behavioural therapy for insomnia (CBTi), which combines a number of psychological strategies to help reprogram the brain.

“For example, cognitive restructuring can help us notice and change negative thinking patterns," notes Stephanie.

“Another example is fear exposure; when I’m nearing finishing treating a patient, I need to help them understand that they'll have some bad nights but actually, it’s totally normal and it’s not going to end the way it used to, which was in a chronic insomnia condition, because they have much more healthy strategies to deal with it now.

“The more they see it that way, the more anxiety reduces, and the quicker it is to actually get back on track and have normal sleep again. 

“We also do Acceptance and Commitment Therapy, which is trying to help you accept and come to terms with the sleep issue and the anxiety issue that can come along with it, as well as the fact there is something we can do about it.

“We've got to help give you that boost and reassurance that you need in order to effectively go against the status quo - which is what you hear in the general population about sleep and is quite wrong - and actually do something that's going to help you.”

CBTi -  “the evidence based, highly scientific way of treating sleep” - is not always available on the NHS, Stephanie says, but it is always worth speaking to your GP if you are concerned about your sleep.

https://www.thesun.ie/health/8799244/how-insomnia-treated-surprising-ways-sleep-expert/

What doctors wish patients knew about insomnia

From ama-assn.org

Even for those who have never acquired SARS-CoV-2, the COVID-19 pandemic has still exacted its toll on health. But it’s not just COVID-19 itself. It’s the anxiety and stress surrounding the pandemic that have contributed to insomnia—the inability to fall asleep or stay asleep. While insomnia was a problem before COVID-19, more people have been fighting a loss of sleep and are unsure of what to do.

Nearly 60% of Americans have struggled with sleep during the pandemic, according to the American Academy of Sleep Medicine. This lack of sleep has led to insomnia, which is a common sleep complaint. About one-third of adults experience acute insomnia, which means they have bouts of sleep loss that last a few days at a time.

But one in 10 suffer from chronic insomnia, which lasts for more than three nights a week for three or more months. Chronic insomnia can lead to increased risk of depression, anxiety, substance abuse and motor vehicle accidents. Over time, this lack of sleep can contribute to health problems such as type 2 diabetes and hypertension.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this instalment, two AMA members who are sleep medicine physicians shared what doctors wish patients knew about insomnia. They are:

• Alejandro D. Chediak, MD, associate professor of medicine and associate chief of clinical affairs in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Miami Miller School of Medicine. Dr. Chediak serves as an AMA delegate for the American Academy of Sleep Medicine.
• Ilene Rosen, MD, MSCE, associate professor of medicine in the Division of Sleep Medicine and assistant dean for Graduate Medical Education at the Perelman School of Medicine at the University of Pennsylvania. 
• 
  

The pandemic contributes to insomnia

“About 25 to 30 million Americans have insomnia at any given time—whether it’s acute or chronic,” said Dr. Rosen. “In the setting of what’s going on in the world—the pandemic, the unrest, the uncertainty now about the world—insomnia is a big player, maybe even more so, now.

“A lot of that in the beginning was the coronasomnia that everyone was talking about,” she said. “But more people are working from home. Pre-pandemic they were just tired because they were getting up for work and doing things at night—i.e., they were sleep deprived.”

Now they don’t have that commute to and from work, and the whole day is in the house—maybe even in the bedroom—so they are finding that they “just can’t sleep,” Dr. Rosen said.

Pay attention to the next-day impact

Patients will often tell their doctor, “I can’t fall asleep, I can’t stay asleep, or I wake up too early,” said Dr. Chediak. “What I try to ascertain from my patients and teach them is that ... the amount of sleep and how long it takes you to fall asleep is not the relevant point.

The question, he said, “is how does that affect you the next day? What can’t you do the next day because you slept badly the day before? I look at it in terms of function—what are the functional outcomes of bad sleep or short sleep? What are the emotional outcomes of bad sleep?

“And then what are the behavioural compensations that might not be conducive to good sleep the next night that subjects adhere to?” Dr. Chediak added. “That tells me a lot about how to fix their problem.”

Insomnia can be a symptom of other problems

An important thing to keep in mind is that “insomnia can also be a symptom” of another condition, said Dr. Rosen. That means, “I can get into bed, and I feel like I don’t sleep straight through the night” because there is an underlying condition involved.

“There are many things that can do that such as sleep apnoea or restless leg syndrome, which can wake you up throughout the night,” she said.

Acute insomnia is caused by a stressor

There are “two big buckets of insomnia as a primary disorder, based on how long the symptoms have been around,” said Dr. Rosen. “You can have acute insomnia in the setting of a stressor” such as the COVID-19 pandemic or a death in the family.

“Acute insomnia is something that causes the brain to be hyper-aroused or hyper-alert … and it occurs over a couple of weeks to months, but the strict definition is less than three months,” she said. “You don’t get into deep sleep, and you notice that you’re having trouble falling asleep, or even just going to sleep for four hours and then you’re wide awake.”

Chronic insomnia can last for months

“The second bucket of insomnia is chronic insomnia, which has lasted more than three days a week for more than three months,” said Dr. Rosen. “Many individuals are able to say, ‘I used to be a good sleeper until a specific stressor happened.’”

“They may have had an acute episode of insomnia and then now the stressor has either gone away or maybe the stressor is still there, but it’s not new,” she said. “And yet the sleep patterns are maintained, meaning the fragmented sleep and the having trouble falling asleep or waking up.”

You can be genetically predisposed

“People have genetic predispositions to insomnia,” said Dr. Rosen, adding “there’s a concept called an insomnia threshold. People who are genetically predisposed live a little bit closer to that threshold so that when they experience a stressor, the brain tips over into the insomnia.

“Some people eat when they’re stressed. Some people cry when they’re stressed. Some people get into bed and sleep more,” she added. “And a certain group of people have trouble sleeping.”

Don’t stress about acute insomnia

“Acute insomnia, whether you are given a medication for it—that is, a sedative to help you sleep—or not, does go away in weeks to months, usually less than three months,” said Dr. Rosen, even if you do nothing.”

That’s why it is important to not “stress about it and keep your routines like you always have, and the insomnia is likely to resolve,” she said. “Certainly, some people find this distressing. If it’s a reactive insomnia—for example, if someone died or there’s a major life stressor—some people find it a lot better to cope during the day if they have gotten some sleep at night, but either way, the brain corrects itself.”

Use sleep trackers with caution

The term “orthosomnia” came out of people watching their Fitbit or Apple Watch, said Dr. Chediak. “They’re obsessed that—I’m not getting eight hours of sleep. My Fitbit or whatever it is that I’m wearing tells me that my sleep is insufficient, light and not refreshing, although one may feel great.”

“This phenomenon, orthosomnia, is a new term based on our ability to technologically monitor something that people think actually is sleep when it doesn’t necessarily mean you’re sleeping,” he said. “The commercially available sleep trackers offer some insight into our patterns of sleep, but they should not be taken literally, particularly when they’re trying to separate deep sleep from light sleep.

“They have absolutely no clue what is deep and what is light sleep,” Dr. Chediak added. “I personally like to look at them when patients bring them up in clinic. They will get better with time, but right now they’re most useful to tell you your pattern when you’re going to bed, when you’re waking up, what are those hours and not to focus on light versus deep.”

Treatment is often behavioural

“Insomnia has a really good response rate to behavioural intervention,” said Dr. Chediak. “About 70–80% of those individuals with chronic insomnia who complete a structured cognitive behavioral therapy for insomnia (CBTi) program will respond favourably, and they can actually exit insomnia altogether.”

“There are several aspects to CBTi—a lot of it involves not obsessing about the insomnia and dialling down the sympathetic tone,” said Dr. Rosen. Instead, “keep the same bedtime and wake time that are about seven or eight hours apart, do not lay in bed awake for more than 15–30 minutes, and engage in activities, such as deep breathing or progressive muscle relaxation.”

“If someone doesn’t have access to a CBTi program, they can consider an online program or even try an app-based program as a first step,” she said.

Melatonin is not good for insomnia

While melatonin can help with jet lag, taking it “randomly doesn’t help because melatonin is not a good sleep drug,” Dr. Chediak explained. “What melatonin does is it tell your brain when you should be shutting down your alertness centres.”

“You need to know in what direction you want to shift, and you need to know what time your brain is at to know when to take melatonin,” he said, adding that “taking melatonin for insomnia is not very effective and may lead to bad dreams, particularly at higher doses.”

“But melatonin is a good drug for circadian changes—changing the intrinsic clock time,” said Dr. Chediak. “All you need is 0.3 milligrams to achieve the change in your circadian clock. Not five, not one, not 10 and not 20. The more you take, the more likely you are to have nightmares or disturbing dreams.”

“The message here is that we don’t use medicines once insomnia has become chronic,” Dr. Rosen said.

https://www.ama-assn.org/delivering-care/public-health/what-doctors-wish-patients-knew-about-insomnia