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Insomnia

Insomnia: Overview, Causes, Diagnosis and Treatment | SingHealth Duke-NUS Sleep Centre

Insomnia - What it is

Insomnia is the complaint of inadequate or poor quality sleep that interferes with normal daytime functioning.

For some people, insomnia means difficulty in falling asleep or waking up frequently during the night with problems getting back to sleep. For others, it is waking up too early in the morning and/or experiencing unrefreshing sleep. It can be transient or chronic.

Everyone has a rough night or two, or short-term (transient) insomnia. Chronic insomnia, though, lasts for more than a month.

You should consider seeking medical advice if your sleep has been disturbed at least several times over the past month, has gone on for weeks and months, or if it interferes with the way you feel or function during the day.

INTRODUCTION

Sleep is essential for health providing rest and restoration for the mind and body. It is the regular period in every 24 hours when we are unconscious and unaware of our surroundings. There are two main types of sleep:

  • Non-REM sleep
    The brain is quiet, but the body may move around. Hormones are released into the bloodstream and our body repairs itself after the wear and tear of the day.
  • Rapid Eye Movement (REM) sleep
    It comes and goes throughout the night and makes up about onefifth of our sleep time. During REM sleep, our brain is very active, our muscles are very relaxed, our eyes move quickly from side to side and we dream.

We move between REM and non-REM sleep about five times throughout the night, dreaming more as we get towards the morning.

During a normal night, we will also have short periods of waking. These last one or two minutes and happen every two hours or so. We are not usually aware of them. We are more likely to remember them if we feel anxious or if there is something else going on - noises outside, our partner snoring etc.

HOW MUCH SLEEP DO WE NEED?

There is no ‘normal’ amount of sleep; more importantly, it is how well you sleep, not how long your sleep is. Sleep requirements change during the course of a lifetime.

  • Babies sleep for about 17 hours a day.
  • Older children require nine or 10 hours per day.
  • Most middle-aged people function best on seven to nine hours of sleep, though some do well with as little as four hours, while others need up to 11 hours.

Older people need the same amount of sleep, but will often only have one period of deep sleep during the night - usually in the first three or four hours, after which they wake more easily.

We also tend to dream less as we get older. Older people also often find that their sleep at night is broken, particularly if they take naps during the daytime.

WHAT IF I DO NOT SLEEP?

The occasional night without sleep will make you feel tired the next day, but it will not harm your physical or mental health.

However, after several sleepless nights, you will start to find that:

  • You are tired all the time
  • You drop off to sleep during the day
  • You find it difficult to concentrate
  • You find it hard to make decisions
  • You start to feel depressed

This can be very dangerous if you are driving or operating heavy machinery. A lack of sleep may also make us more vulnerable to high blood pressure, obesity and diabetes.

Insomnia - Symptoms

Insomnia - How to prevent?

Insomnia - Causes and Risk Factors

Insomnia is a symptom of another problem. It can be caused by any of a number of factors.

Psychological Factors

Tendency to insomnia
Some people seem more likely than others to have insomnia during times of stress.

Other people respond to stress by getting a headache or stomach ache. Knowing that you are likely to get insomnia, and that it will not last too long can be helpful in dealing with it when it happens.

Persistent stress
Relationship problems, a child with a serious illness or an unrewarding job may contribute to sleep problems. Learning to deal with stress may help treat your insomnia.

Psychophysiological (learned) insomnia
If you sleep poorly during times of stress, you may worry about not being able to function well during the day. You may decide to try harder to sleep at night. This usually makes things worse.

After a few nights, some of the things you do to get ready for bed may remind you of your trouble sleeping. Changing into your night clothes and turning off the lights will suddenly make you wide awake.

Some people with psychophysiological insomnia may fall asleep quickly when they are not in bed. They may drift off on the couch, while reading the newspaper, watching television or driving.

Even a few nights of poor sleep during a month can trigger psychophysiological insomnia.

Lifestyle

Stimulants
Caffeine keeps people awake. If you have coffee in the evening, your sleep will be less restful, even if it does not keep you from falling asleep.

Nicotine also keeps people awake, and smokers may take longer to fall asleep than non-smokers. Many medications have stimulants in them. These include weight-loss, anti-allergy and asthma medications. Some cold remedies also have stimulants in them.

Alcohol
You may think having a glass of wine at bedtime will help you sleep. But alcohol, while it may help you fall asleep quickly, is likely to make you wake up briefly throughout the night.

Work hours
If you are a shift worker, you are more likely to experience sleep problems. This includes workers who have changing shifts. It also includes people who work nights or early mornings.

Keeping the same schedule, even on weekends, is important. It can help to programme your body to sleep at certain times and to stay awake at others.

Waking up at the same time every morning is one way to establish a stable sleep pattern. Having a routine is important.

Exercise
You may think that resting and having a quiet lifestyle helps to prevent insomnia. In fact, people who get little or no exercise may find it hard to sleep at night.

Regular exercise helps people to sleep better. The best time to exercise is in the afternoon. Do not exercise close to bedtime. Leave at least two hours before your bedtime for your heart rate to slow down after the exercise.

Sleeping pills
Sleeping pills should be used as directed by your doctor. Some sleeping pills stop working after a few weeks if they are used every night.

If you stop using them suddenly however, your sleep may be worse for a time. This problem can be reduced, by cutting back slowly on the use of sleeping pills. Your doctor will help you with this.

Environmental Factors

Noise
Keep the bedroom as quiet as possible. Passing traffic, airplanes, the television and other noises can disturb your sleep even when they do not cause you to wake up.

Light
Use shades or heavy curtains to keep your bedroom dark. Light comes through your eyelids even when your eyes are closed. Light can disrupt your sleep.

Physical and Psychiatric Illness

Many medical problems can disrupt sleep and lead people to complain that they have insomnia.

Psychiatric problems, other sleep disorders and physical illnesses may change your sleep in ways that can be easily mistaken for insomnia. Treating the medical disorder may treat the insomnia.

Medical illnesses
These include gastric reflux with heartburn, chronic obstructive lung disease, asthma, congestive heart failure, menopausal hot flashes, arthritis and other causes of chronic pain, and overactive thyroid. 

Psychiatric problems
One kind of insomnia – waking up very early – is one of the most common complaints of people with depression.

If you have a psychiatric disorder, you may sleep poorly. Treatment of the underlying disorder can help to improve your sleep.

Sleep disorders
These include obstructive sleep apnoea, periodic limb movement disorder and a restless leg syndrome.

Insomnia - Diagnosis

People with insomnia are evaluated by a psychiatrist for a thorough medical and sleep history. An overnight sleep study may be recommended if there is a suspicion that there may be a primary sleep disorder, such as sleep apnoea.

Your doctor can make sure that your sleeplessness is not the result of a physical illness, a prescribed medicine, or emotional problems and make appropriate recommendations and treatment. You may be asked to keep a sleep diary showing sleeping and waking patterns for a week or two.

Insomnia - Treatments

Treatment will depend on the cause of the insomnia. A combination of behavioural approaches and medications are usually offered.

Nearly everyone can benefit from an improved sleep hygiene. People with sleep disorders should work with their doctors to diagnose the problem and treat conditions that may be responsible.

If your doctor diagnoses primary insomnia, consider behavioural therapy first, then discuss the proper use of prescription sleeping pills.

GOOD SLEEP HYGIENE

These simple tips can help you get a good night’s sleep:

1. Do not go to bed unless you are sleepy.
If you are not sleepy at bedtime, then do something else. Read a book, listen to soft music or browse through a magazine. Find something relaxing but not stimulating to take your mind off of worries about sleep. This will relax your body and distract your mind.

2. Use your bed only for sleeping and sex and never for reading or watching TV.
If you are not asleep after 15 - 20 minutes, get out of bed. Find something else to do that will make you feel relaxed.

If you can, do this in another room. Read quietly with a dim light, but do not watch the TV since the fullspectrum light emitted by the TV has an arousing effect.

Similarly, using your phone just before your bedtime is not recommended due to the arousing effect from the light emitted. When you feel sleepy, get back into bed.

3. Do not nap during the day unless it is absolutely necessary.
Even then, restrict your nap to 15 - 20 minutes in the early afternoon.

4. Begin rituals that help you to relax each night before bed.
Establish a regular bedtime and a relaxing bedtime routine, such as taking a warm bath or listening to soothing music.

Whenever possible, wind down late in the day, such as by scheduling stressful or demanding tasks early, and the less challenging activities at a later time.

5. Get up at the same time every morning.
Do this even on weekends and on holidays.

6. Eat properly and practise healthy habits.

  • Do not go to bed hungry, but do not eat a big meal near bedtime either. 
  • Avoid caffeine, especially after mid-afternoon.
  • Avoid alcohol after dinner time; although many people think of it as a sedative, alcohol can actually impair the quality of your sleep.
  • Try to avoid all beverages after dinner if you find yourself getting up at night to urinate.
  • Do not have a cigarette or any other source of nicotine before bedtime.
  • Get plenty of exercise early in the day. Avoid any tough exercise within three hours of your bedtime.

7. Make your bedroom quiet, dark and a little bit cool.
Your bedroom should be wellventilated and kept at a constant, comfortable temperature.

Try using a sleep mask or ear plugs to compensate for any problems in your sleeping environment.

8. Above all, do not worry about sleep.
Watching the clock never helps. Except when keeping a sleep diary, do not keep track of the amount of time you spend trying to sleep. Instead, rest quietly and peacefully.

Try not to lie in bed reviewing your problems and plans. If you are overloaded, get out of bed and make a list. Then return to bed and think of something relaxing and pleasant.

COMMON (PSYCHOLOGICAL) BEHAVIOURAL APPROACHES

Relaxation therapy
Learn deep breathing, progressive muscle relaxation or meditation. These techniques help to reduce or eliminate anxiety and body tension.

Relaxing your mind at bedtime will help you drift off to sleep. It takes much practice to learn the techniques and to achieve effective relaxation.

Stimulus control therapy
Go to bed only when you are sleepy. Do not read, watch the TV or snack in bed. Get up at the same time every day, no matter how little sleep you have had.

Avoid daytime napping. This technique helps to recondition you such that you associate the bed and bedtime, with sleep only.

Sleep restriction therapy
Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. If this is the case for you, reduce your time in bed to the estimated total time you sleep in an average night (minimum five hours) by going to bed at a later time.

Get up at the same time every day. Maintain the same bedtime every night for a week, and then move it 15 minutes earlier every week until you get a satisfying, relaxing amount of sleep. Then maintain the same schedule every day.

Cognitive therapy
Learn to replace negative thoughts about sleep (‘I will never get to sleep tonight’, ‘I will not be able to function tomorrow’, or ‘I will fall sick unless I sleep eight hours a night’) with positive thoughts (‘If I relax peacefully in bed, my body will take care of itself’).

MEDICATION

People have used sleeping tablets for many years, but we now know that:

  • They do not work for very long.
  • They leave you tired and irritable the next day.
  • They lose their effect quite quickly, so you have to take more and more to get the same effect.
  • Some people become addicted to them. The longer you take sleeping tablets, the more likely you are to become physically or psychologically dependent on them.
  • There are some newer sleeping tablets (Zolpidem and Zopiclone), but these seem to have many of the same drawbacks as the older drugs, such as Valium and Ativan.

Sleeping tablets should only be used for short periods (less than two weeks) - for instance, if you are so distressed that you cannot sleep at all.

If you have been on sleeping tablets for a long time, it is best to slowly cut down the dose after discussing it with your doctor. In some cases, antidepressant tablets may be helpful.

Over-the-counter medications are not usually recommended, for the treatment of insomnia.

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