Insomnia Disorder

To be diagnosed with insomnia disorder, a person must present with one or more of the following three main symptoms at least three nights per week for at least three months. You must have difficulty sleeping, even with ample opportunity and an environment conducive to sleep, and your symptoms must not be better explained by another sleep-wake disorder diagnosis.

Main insomnia disorder symptoms

The three main symptoms of insomnia disorder are:

• Trouble falling asleep (also known as onset insomnia)
• Difficulty staying asleep once you’ve fallen asleep (also known as middle insomnia)
• Wakefulness in the early morning hours (also known as late insomnia)

Those with insomnia disorder may experience a range of cognitive and behavioral secondary symptoms as a result of lack of sleep. These symptoms of insomnia disorder can affect day-to-day functioning, including social life, work or school performance, and an increased risk of accidents. Often, insomnia disorder is characterized by nocturnal and diurnal symptoms.

Secondary insomnia disorder symptoms

The secondary symptoms of insomnia disorder include:

• Fatigue
• Impaired memory or attention
• Irritability or heightened aggressiveness (especially in children) 

A person may have symptoms of insomnia without having insomnia disorder, as insomnia can be a feature of some mental health conditions, as well as medical conditions. To be diagnosed with insomnia disorder, an individual must meet all criteria laid out in the DSM-5 regarding time frame and impairment.

It can be hard to pinpoint the cause for the disorder - insomnia can develop as a result of various reasons. Researchers have not targeted a single cause for insomnia disorder; however, there can be several factors that contribute to the disorder. Physiological arousal may be caused by higher body temperature, increased cortisol levels, or rapid heartbeat. 

Insomnia disorder may also be comorbid² with other mental health disorders like anxiety or depression. Stress can be a significant factor in cases of both physical and mental causes for insomnia disorder.

Risk of insomnia disorder

Some people may be more susceptible to insomnia symptoms. Below are a few risk factors for insomnia disorder: 

• Family history of insomnia
• Being assigned female at birth (AFAB)
• Chronic pain
• Lower socioeconomic status
• Experiencing a mood disorder

In rare cases, insomnia can be caused by a disease known as fatal familial insomnia, a rare genetic degenerative brain disorder that causes progressive symptoms. 

Treatment of insomnia disorder may begin with therapy. If therapy alone is not successful, medication may be prescribed by a doctor. Certain lifestyle habits may also be recommended in the treatment of insomnia disorder. 

Medication for insomnia 

Insomnia disorder can make it hard to fall asleep. For insomnia that does not respond to therapy, a psychiatrist or another doctor may prescribe medications for sleep.

Medications like short or immediate-acting benzodiazepines (most likely for short-term use), sedating antidepressants, anti-epilepsy medications, atypical antipsychotics, and other medications with sedating effects might be prescribed for insomnia disorder. Medications that promote sleep often have side effects like confusion, sleepwalking, and daytime drowsiness. However, ask your doctor about the side effects unique to the medication you are taking.

Consult with a doctor before starting, changing, or stopping a medication. The information provided in this article is not intended as medical advice. Consult your prescribing doctor for personalized guidance. Your doctor may want to monitor your blood pressure and other measures before prescribing new medication.    

A doctor may also order a sleep test, which is often used to assess someone for sleep disorders. In some cases, such a test can be conducted at home to test for sleep apnea.  

Other treatment options

Sometimes a supplement called melatonin is prescribed for sleep disturbance or difficulties. Melatonin is a hormone that occurs naturally in the body, and works by causing the sensation of becoming sleepy. Prescription melatonin works in the same way as this hormone, signaling to your brain that it’s time to sleep. 

Melatonin is a popular supplement sold for treatment of insomnia. However, some experts do not recommend it, as there is not enough evidence that it works. In addition, there is no government control of supplements, so there’s no verifiable way (beyond third-party testing) to know whether the amount of melatonin in the supplement matches what is stated on the label.

Light therapy may be helpful for treating insomnia disorder. Sunlight can control circadian rhythms, telling your body when it is time to be awake and when to sleep. When this cycle is out of alignment, sitting in front of a light box that mimics sunlight at specified times may reset the body clock. 

Other solutions offered by the alternative medicine community, including homeopathy, acupuncture, acupressure, or hypnosis, are not evidence-based. Discuss these techniques with your doctor before trying them. 

Self-care

There are a number of tips and strategies for getting a better night’s sleep, including the following forms of sleep hygiene (or sleep habits): 

• Avoiding, reducing, or limiting caffeine, tobacco, and alcohol within a certain number of hours prior to sleep, as they can interfere with a person's circadian rhythm, which promotes healthy sleep
• Avoiding daytime naps, as naps can make it more difficult to become sleepy at night
• Keeping your sleep schedule consistent, even on weekends
• Turning off screens and not using electronics at least one hour before bedtime 
• Getting moderate physical activity daily, but not within an hour of sleeping 
• Ensuring your bed is used only for sleeping and sex
• Avoiding eating heavy meals close to bedtime
• Keeping your bedroom cool, dark, and quiet
• Keeping a sleep diary

CBT-I for insomnia disorder is an evidence-based practice that may establish a healthy baseline for sleep. A licensed therapist can guide you through exercises and techniques to manage the stress that can be an effect of, as well as contribute to, insomnia disorder. They may also partner with you to help manage symptoms of any concurrent mental health disorders. 

Insomnia disorder therapy

Certain specialized therapy modalities like CBT-I may not be readily available to people in certain geographic locations. For this reason, online therapy has become an increasingly common solution for those who are seeking therapy. Online therapy platforms like BetterHelp match you with a therapist using an online questionnaire, so that you can work with someone who meets your needs, often matching clients within 48 hours of signing up. Therapy sessions can take place over video conferencing, messaging, or the phone. With therapy, you may gain insight that helps you fall asleep and then stay asleep through the night. 

A paper published in 2021 found that consecutive sleep loss (commonly known as “sleep debt”) was connected to degraded daily affective and physical well-being. Daily negative affect increased as consecutive sleep loss increased, while positive affect decreased. The study concluded that attempting to avoid consecutive nights of sleep-loss can be beneficial to well-being. 

In an eight-year study published in 2021, researchers found that chronic sleep problems were associated with a greater risk of dementia. In addition, this same study reports an association with sleep problems and an overall greater risk of all-cause mortality in older adults. Another study published in 2020 indicated that over half of the participants experienced remission within five years of experiencing their first episode of insomnia.

Below are several key statistics on insomnia disorder:

• In 2020, the groups that reported the highest levels of short sleep duration were men (33.4%), adults ages 24 to 44 (36.4%), non-Hispanic Native Hawaiian and Other Pacific Islander (47%), and non-Hispanic Black or African American (43.5%).
• Insomnia may be a common sleep disorder. More than a third of adults in the United States sleep less than seven hours per night on average.
• It is estimated that between 50 to 70 million people in the United States experience ongoing (chronic) sleep disorders.
• With proper treatment, research suggests that about 75% of individuals experiencing insomnia symptoms can achieve positive sleep hygiene.