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Sleeping difficulty

Alternative names

Insomnia; Inability to sleep; Dyssomnia; Sleeplessness; Wakefulness


Chronic and persistent difficulty in either (1) falling asleep (initial insomnia), (2) remaining asleep through the night (middle insomnia), or (3) waking up too early (terminal insomnia). All types of insomnia can lead to daytime drowsiness, poor concentration, and the inability to feel refreshed and rested in the morning.


Insomnia is not, by itself a disease, but it is an occasional problem for over 70 million Americans. Every year, 98 million dollars are spent on over-the-counter sleeping aids and another 50 million on caffeine tablets to stay wake during the day.

Everyone has an occasional sleepless night, of course, but for most people, this is not problematic. However, as many as 25% of Americans report occasional sleeping problems and insomnia is a chronic problem for about 10% of the population. In these cases, people will be unable to carry out their daily responsibilities either because they are too tired or because they have trouble concentrating due to lack of restful sleep.

Most adults do best with about 8 hours of sleep a night until age 60, after which 6 hours may be adequate. Even though the elderly need less sleep, almost one-half of people over 60 experience some degree of insomnia.

The best measure of the amount of sleep needed is how you feel. If you awaken feeling refreshed, you are getting enough sleep. For some people, this may take only 4 hours -- others can need up to 10 hours to feel rested.

The use of long-acting or high-dose sedatives as a cure for insomnia can increase daytime drowsiness -- over time, making the problem worse, not better.

The use of antihistamines (the main ingredient in over-the-counter sleeping pills) as a cure for insomnia can also lead to similar difficulties. Chronic antihistamine usage may also lead to reversible memory impairment.

Stronger tranquilizers, available by prescription, often induce drug tolerance and do not produce a natural, restful sleep. As a result, one may feel more dependent on the drug and may conclude that more of the drug is needed. The more drug used, the more side effects and tolerance develop. Upon discontinuation of these tranquilizers, rebound worsening of insomnia is very common.

A life-threatening disease is rarely the cause of problems with sleep. For many people, poor sleep habits are the cause. However, because insomnia is a key symptom of depression, you should be evaluated for depression if you are having sleeping difficulties.

Insomnia may cause a reduced energy level , irritability, disorientation, dark circles under the eyes, posture changes, and fatigue .

Counseling may be helpful for psychological disorders that lead to insomnia; antidepressants can often help both the sleeping problem and the depression. Antidepressant medications are not abusable and do not lead to the feeling of a need for increased doses the way many prescription sleeping medications can.

Nightmares and dreams that interfere with sleep may also respond to psychological interventions.

Common Causes

  • jet lag
  • shift work
  • wake-sleep pattern disturbances
  • grief
  • depression or major depression
  • worry
  • anxiety or stress
  • exhilaration or excitement
  • bed or bedroom not conducive to sleep
  • nicotine, alcohol, caffeine , food, or stimulants at bedtime
  • aging
  • excessive sleep during the day
  • excessive physical or intellectual stimulation at bedtime
  • overactive thyroid ( hyperthyroidism )
  • taking a new drug (medication side-effect).
  • alcoholism or abrupt cessation of alcohol after long-term use
  • inadequate bright-light exposure during waking hours
  • abruptly stopping a medication (such as sleeping pills).
  • medications or illicit "street drugs" (for example, excessive thyroid replacement hormone, amphetamines, caffeine-containing beverages, cocaine , ephedrine, phenylpropanolamine, theophylline derivatives)
  • withdrawal of medications (such as sedatives or hypnotics )
  • interference with sleep by various diseases, including an enlarged prostate (men), cystitis (women), COPD , pain of arthritis , heartburn , and heart or lung problems
  • restless leg syndrome
Most newborn babies wake several times during the night, but by the age of 6 months they typically sleep through the night. At one year, babies will sleep an average of about 16 hours in every 24. Two to three hours of this sleep will be during the day. Causes of sleeplessness in infants may include:
  • desire for parental attention
  • infantile colic or other digestive problems (worms)
  • indigestion
  • hunger
  • teething
  • fever or other illness

Home Care

Exhaust every possible option before resorting to drugs to cure insomnia.

Practice good sleep hygiene: avoid using alcohol in the evening. Avoid caffeine for at least 8 hours before bedtime. Give up smoking (nicotine is a stimulant).

Establish a regular bedtime, but don't go to bed if you feel wide awake. Use the bedroom for bedroom activities only. Once in bed, use creative imagery and relaxation techniques to keep your mind off unrestful thoughts. Avoid staying in bed for long periods of time while awake, or going to bed because of boredom.

Take your TV or computer out of your bedroom. If not, your brain becomes used to the stimulation and starts to expect it when you are there. This makes it harder for you to fall asleep.

Relax by reading, taking a bath, or listening to soothing music before getting to bed.

A snack before bedtime helps many people. Foods such as warm milk or turkey have a natural sleep inducer called L-tryptophan.

Exercise regularly, but not in the last two hours before going to bed. Exercise, especially aerobic exercise, has been show to make people fall asleep faster and benefit from deeper and more restful sleep. Sex can be a natural sleep inducer and helps some people.

Avoid emotional upset or stressful situations prior to bedtime.

Avoid being readily available to a child during the night; otherwise, the child may become dependent on attention and become sleepless if deprived of it.

For children who have trouble falling asleep, try to make sure that the child is not disturbed by unnecessary noise. Leaving a radio playing soft music may help cover up disturbing noises.

Avoid sending a child to bed as punishment which can result in poor sleep caused by fear.

Never give a child sleeping medicine without consulting the doctor first. Generally, it is unwise to treat the problem with drugs.

Medication should be a last resort.

Antihistamines such as Sominex, Nytol, and Compoz (all approved by the FDA) are available without a prescription. These medications are not without side-effects: some people complain of a "hangover" effect the next morning.

If these fail, you may want to ask you health care provider to recommend other options.

Avoid all sedatives, including the benzodiazepines, during the first 3 months of pregnancy.

Call your health care provider if

  • a sleeping problem becomes persistent and unbearable despite home treatment.
  • if sleeping problem occurs more than 3 nights per week for more than 1 month
  • if the insomnia is accompanied by other worrisome symptoms such as chest pain or shortness of breath .

The medical history will be obtained and a physical examination performed.

Medical history questions documenting your symptom in detail may include:
  • type
    • Do you have difficulty falling asleep or staying asleep (insomnia)?
    • Do you awaken from sleep not feeling rested?
    • Do you awaken many times at night?
  • time pattern
    • Is the problem persistent?
    • For how long?
    • Did the problem seem to be resolving after changing your work shift pattern?
  • aggravating factors
    • Did it begin after stopping the use of alcohol at bedtime?
    • Did it begin after stopping the use of a sleeping aid
    • What medications do you take?
    • Do you take any herbal supplements or alternative medicine remedies?
    • Do you drink much coffee? Have you recently cut down on your coffee intake?
    • Is there any excessive stress or anxiety ?
  • sleep schedule
    • How much do you normally sleep? What hours?
    • What do you do during the few hours before you go to bed?
    • Do your sleep schedule change frequently? (shift work)
    • Do you fall asleep at inappropriate times or places?
    • Does your sleep schedule change drastically on weekends?
  • associated complaints
    • Does it occur in response to reminders of a traumatic event ?
    • Does it occur around the time you ingest some form of a stimulant substance?
    • Does it occur around the time you use a hypnotic medication?
    • Are you associating the bedroom with insomnia?
    • Do you worry excessively about sleep?
    • Are there also breath holding spells or times of snoring ?
    • Do you have physical aches or pains that prevent you from sleeping?
    • What other symptoms are also present?
Diagnostic tests that may be performed include:
  • sleep log record
  • psychological tests
  • thyroid tests ( TSH , T3 , T4 )

In some rare cases, your health care provider may want you to see a sleep medicine specialist who will perform a sleep study (polysomnography)

In most cases, this will not be necessary. Your health care provider can explore with you the possibility of using prescribed medications if everything else has failed.

Some antidepressants such as Elavil (amitriptyline) can be used at bedtime because they are sedating. They require a prescription. If insomnia is caused by depression, proper treatment of the depression with other appropriate medications or therapy should solve the problem. Benzodiazepines such as Valium (diazepam) or Ativan (lorazepam) are anti-anxiety medications that can also help induce sleep. They must be used with caution because they can be addictive. They too require a prescription.

Newer medications called hypnotics are now available. They are help reduce the time needed to fall asleep but are far less likely to be addictive than benzodiazepines. Ambien (zolpidem) and Sonata (zaleplon) are two examples.

After seeing your health care provider:
If a diagnosis was made by your health care provider related to sleeping difficulty, you may want to note that diagnosis in your personal medical record.

Update Date: 12/11/2001

Benoit Dubé, M.D., Department of Psychiatry, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.

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Last updated: Tue, 06 Jan 2009 00:20:03 GMT