Primary insomnia is a condition on its own

Insomnia can refer to difficulty getting to sleep, difficulty staying asleep, waking up early without being able to return to sleep, or a combination of the three. Problems with sleep are often associated with medical conditions (e.g., arthritis, diabetes, chronic pain, restless leg syndrome), mental health conditions (e.g., depression, anxiety), as well as the use of drugs, alcohol, and medications. This type of insomnia is called secondary insomnia because there is an underlying cause for the difficulty sleeping. However, insomnia sometimes has no underlying cause and is then referred to as primary insomnia.

Insomnia can be short- or long-lasting. Short-term insomnia (e.g., the sleeplessness that occurs just before a big test) is very common and is considered a normal stress reaction that typically disappears as the stress passes. Chronic insomnia, on the other hand, refers to sleep problems that occur at least 3 nights a week and have lasted over 1 month.

Short-term insomnia (e.g., the sleeplessness that occurs just before a big test) is very common and is considered a normal stress reaction that typically disappears as the stress passes. Chronic insomnia, on the other hand, refers to sleep problems that occur at least 3 nights a week for over 3 months and cause distress or affects functioning.

Insomnia sometimes causes more insomnia

Sometimes, paradoxically, the habits that people develop to cope with their nighttime sleeplessness delays the return of normal sleep patterns. These problematic habits include napping during the daytime, giving up on regular exercise because of fatigue, or drinking excessive amounts of coffee to promote alertness.

The practice of good sleep hygiene assists in re-establishing normal sleep patterns.

Seeking treatment for insomnia

Treatment for disturbed sleep should be sought when it has lasted more than a few weeks, and is associated with daytime problems such as mood changes, or difficulty focusing or staying alert. For a doctor to diagnose primary insomnia, all other possible causes of disturbed sleep have to be eliminated first. To do this, the doctor will ask detailed questions, including a sleep history (when and how long you sleep, how you feel before you fall asleep and when you wake up, specific sleep behaviours such as snoring and limb-twitching), as well as a medical and a mental health history. A physical examination and certain lab tests may be required.

If the sleep problem is chronic, your doctor may ask you to keep a sleep diary. This provides the best information about the actual sleep performance, its night-to-night variability, and its effects on daytime functioning.

Treatment of insomnia

Treating insomnia emphasizes:

  • treating the underlying cause
  • stress reduction
  • good sleep hygiene
  • strategic use of sleep-promoting medications

If another medical condition (e.g., pain from arthritis or depression) is causing insomnia, then the underlying cause should be treated first. Some people may require help with their sleep while the underlying cause is getting treated.

Since falling asleep is a passive process that requires the body and mind to be relaxed, strategies that calm both the mind and body are very helpful in managing insomnia.

Exercise has a direct, beneficial effect on several factors that affect insomnia. It reduces the effects of stress, improves mood, and deepens sleep. Regular, daily exercise completed at least 4 hours before bedtime usually improves sleep significantly.

Relax before bedtime: To ensure a relaxing "buffer zone" before bedtime, it is helpful to stop all work-related tasks 90 minutes before going to sleep. Other helpful relaxation strategies include relaxation exercises (focusing on breathing and muscle relaxation) or gentle exercise such as yoga.

"The 20-minute rule" is a technique often used in conjunction with sleep hygiene practices. The goal is to associate being in bed with being asleep. If, after turning the lights out or waking up, you don't fall asleep in what feels like 20 minutes, you should get up and only return to bed when feeling "drowsy-tired." (Clock watching is an arousing activity; all clock faces should be turned away.)

This step is repeated throughout the night as necessary until the morning alarm goes. The amount of "awake" time during the night will create a degree of sleep deprivation that will increase sleep pressure the next night. In this way, over time, sleep improves.

Sleep restriction is another method that reduces the "awake" time in bed, and increases the depth and quality of sleep. First, the average current sleep time is calculated from the sleep diary. This is done by subtracting all "awake" time from the total time spent in bed. This "sleep time" may be, say, 5 hours and 20 minutes. This amount of time is the new assigned time in bed. Depending on your preference (morning types prefer to be up early; evening types prefer to be up late) the new arising time is set and kept constant, and you will go to bed 5 hours and 20 minutes before the selected get up time.

Like the "20-minute rule," sleep restriction usually results in a mild degree of sleep deprivation (daytime sleepiness and fatigue), but creates increased sleep pressure at night. Once this begins to occur, the doctor will increase the allowed time in bed by 10 to 15 minutes. In this way, the time in bed is slowly increased until sleep again becomes disrupted. Then the previous sleep time associated with no awakenings becomes the new sleep time.

Sleep medications should only be used for the shortest period of time possible and in the lowest dose. This is because sleep medications, when used regularly, become less effective over time and may be habit-forming. Specific medications which promote sleep include temazepam, zopiclone, and zolpidem. To avoid daytime sedation, long-acting medications (including non-prescription antihistamines) should not be used.

original article by Jon Fleming, MD,
with revisions by the MediResource Clinical Team