Causes of Insomnia


Half of all Americans have experienced insomnia, which can afflict its sufferers in a variety of ways.

Insomnia, or the inability to sleep, can take many forms.

Have you ever crawled into bed exhausted, thinking you'd fall asleep in seconds, only to find yourself still awake an hour later? Or maybe you tend to fall asleep quickly but wake up many times through the night. Or perhaps you wake up at 4 or 5 a.m. and can't get back to sleep, even though you still feel tired and don't have to get up until 7 a.m. These are all versions of insomnia.

If you can relate to any of these scenarios, you're in good company. Half of all Americans have experienced insomnia at some time in their lives, and a good number experience it on a regular basis.

Insomnia is a broad term that describes trouble going to sleep, staying asleep, or sleeping for the full time you need to in order to feel refreshed. Insomnia, like other secondary sleep disorders, is most often a symptom that some other physical, emotional, behavioral or environmental problem is affecting sleep. Most researchers characterize the different types of insomnia by frequency and length of time it continues. The following are the main forms of insomnia.

  • Transient, or temporary, insomnia typically lasts between one and several nights and is usually caused by stress or emotion.
  • Intermittent insomnia occurs off and on over a long period of time and is also most frequently a result of stress or anxiety.
  • Chronic insomnia occurs on most nights, lasts at least two weeks (and possibly much longer), and may result from one or more medical conditions.

Transient and intermittent insomnia are usually best treated by practicing some proven methods of stress reduction and/or changing your sleep environment. Chronic insomniacs may also need professional help, especially if their sleeplessness is related to a medical condition.There are several medical conditions -- heartburn, for example -- that can affect sleep. The link between heartburn and insomnia is discussed on the next page.For more information on how to get a good night's sleep, see:

Heartburn and Insomnia

Most of us have had that burning or gnawing sensation in the middle of the chest that signifies a case of heartburn. Despite its name, heartburn has nothing to do with the heart. It is really caused when the esophagus, the tube that connects the mouth to the stomach, is exposed to the highly acidic contents of the stomach.

When this occurs, the material in the stomach is said to "reflux," or back up, into the esophagus. It is this strong acid in the esophagus that causes the burning sensation. In addition to the burning, or sometimes in its absence, you may have a bitter taste in your mouth and intense coughing fits, both due to the acid.

Reflux is most likely to occur when you are lying down. In this position, the force of gravity does not help move food from the stomach into the small intestine, where it is supposed to go. Because we generally sleep in a horizontal position (unless you are so sleep-deprived that you fall asleep in a chair), reflux is most common at night. Sleep apnea may also cause reflux through a siphoning effect that pulls stomach contents up into the esophagus.

You should consult your doctor if you regularly experience reflux. Your doctor may recommend you make some of the following changes in your diet and your lifestyle:

  • Avoid alcohol.
  • Avoid heavily spiced foods and other common heartburn-causing foods such as chocolate, peppermint, and coffee.
  • Control your weight.
  • Manage stress.
  • Don't eat heavy meals within three hours of going to bed.
  • Don't lie down within an hour after eating.

One technique that may help is to elevate your head at night to allow gravity to work for you. This can be done by placing bricks under the bedposts at the head of the bed. Another option is to place several pillows under your head and shoulders to raise your upper body during sleep (but be careful not to bend your neck).

You might also consider an electronically adjustable bed, similar to the ones used in hospitals. Although it is certainly a more expensive option than a few pillows, some insurance plans will cover an adjustable bed if a medical condition requires its use. If apnea is the cause of your heartburn, it needs to be treated.Another bodily function can also cause insomnia. Find out how frequent urination can rob you of sleep on the next page. For more information on how to get a good night's sleep, see:

Insomnia and Nighttime Urination

Nighttime urination can cause insomnia, but it can be a factor in more serious conditions as well. At worst, it could be a symptom of an enlarged prostate or diabetes. Even at its best, it can be frustrating and leave you fatigued.

There you are, having a pleasant night's sleep. Gradually a familiar pressure is building in your lower abdomen. When you awaken enough to make sense of the discomfort, you realize it's time for another trek to the bathroom -- your fourth since crawling into bed earlier that night. It's become routine, but should it be?

Nighttime trips to the bathroom may simply mean you consumed too much fluid in the evening. And, certainly, the need to urinate once during a night's sleep is not cause for concern. But needing to urinate two or more times every night requires investigation.

First of all, each trip to the bathroom means you have to wake up. Numerous trips each night, combined with the time it takes to return to sleep, may add up to a significant amount of lost sleep over time.

But more important than the loss of sleep, this pattern could signal a medical problem. Excessive urination at night (called nocturia) is a common symptom of several conditions, including diabetes. In men, an enlarged prostate gland (a problem that occurs in most men as they age) is very often the problem. An enlarged prostate can also be a warning sign of prostate cancer and should be evaluated promptly. In women, urinary tract infections frequently cause nocturia. Sleep apnea can also cause nocturia.

Drinking alcohol in the evening can be a factor in nocturia. And many prescription drugs have nocturia as a side effect. Because nocturia has so many causes, a doctor's evaluation is important. Afterward, your doctor may refer you to a urologist or other specialist.

If you have to use the bathroom at night, use only the minimum amount of light to navigate. Too much bright light may make it difficult to return to sleep. If getting up is a nightly occurrence for you, light the path to the bathroom with nightlights so you don't have to turn on any lights.

An enlarged prostate is one effect of growing older that may lead to insomnia. As people age, their reproductive systems change, too. The next page explains how these changes may cause you to lose sleep.

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Insomnia and Reproductive Issues

Insomnia can result from reproductive issues in either men or women, although specific causes are unique to each gender.

Menopause

As women approach menopause, hormone levels begin to shift. This shifting causes an imbalance between the female hormones estrogen and progesterone and is responsible for an increase in sleep disturbances. As if hot flashes, vaginal dryness and thinning bones weren't enough, insomnia is also a common occurrence during menopause. Hormonal fluctuations can cause insomnia indirectly as a result of frequent hot flashes and night sweats during menopause.

Hormone replacement therapy has improved the sleeping patterns of many women. In addition, some women have found dietary changes and natural remedies to be helpful. These will be addressed in Chapter Five.

Male Hormones and Sleep Problems

While men experience a "lite" version of menopause, they nonetheless go through a similar shifting of hormones. Decreases in testosterone can result in sleep disturbances, especially later in life when testosterone production falls off sharply.

Pregnancy

Pregnancy can temporarily interfere with restful sleep for a number of reasons.

  • Increased need to urinate during the night
  • Baby's kicking can awaken the mother
  • Nausea and/or heartburn
  • Hemorrhoids
  • Leg cramps and restless legs syndrome
  • Discomfort in many sleeping positions, especially in the third trimester

Most, if not all, of these symptoms associated with pregnancy will stop once the baby is delivered. But it is after delivery, of course, when the real sleep deprivation begins, at least for a while. The best treatments for sleep-disruptive nightly feedings are frequent naps and lots of helping hands.Even with help, caring for a newborn is a stressful time. Find out on the next page how stress can trigger insomnia.

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Insomnia and Stress and Mood

Stress and moods are complicated, and the relationship between each and sleep is equally complicated. In some people, though, stress and mood disorders can bring on insomnia.

Stress

Stress also has a major effect on sleep. Stress can be best understood as a reaction to either an external stimulus (such as a difficult work situation or an upcoming wedding) or an internal one (such as illness or pain), or both. People respond to stress in different ways. Some people, especially younger people, use sleep as an escape from emotional distress and may spend a large portion of their day in bed. Under these circumstances, sleep can occupy 12 hours of the day or more. Others find stress leads to insomnia.

It's important to remember that stress can result from positive as well as negative situations. Graduations, weddings, vacations and other pleasant events can cause stress and anxiety as well. They can also affect your sleep. Insomnia related to these kinds of events usually goes away when the event is over (unless you're still scrambling to pay the bills from that elaborate wedding).

To limit the effect that stress has on your sleep, you need to work on how you react to stress.

Mood Disorders

Did you know that depression, anxiety, and other emotional disturbances can affect your sleep? The reverse is also true: Poor sleep can cause depression, anxiety, irritability and even changes in personality. Sometimes both occur at once, resulting in a very difficult cycle to break. Understanding the possible connection between sleep disorders and mood disorders can help you get to the root of both problems.

Depression and anxiety are two of the most common mental disorders that interfere with sleep. There are many types of depression and variations on the way it can affect sleep patterns. One type of depression, called manic-depressive disorder, can produce an extreme form of insomnia in which the individual sleeps only four hours or less each night. The sleeplessness causes an exaggerated and potentially harmful sense of euphoria rather than sadness.

If you believe that a mood disorder is affecting your sleep and the symptoms persist for more than three weeks, it is advisable to seek professional help. The first call should be to your doctor, who can examine you to rule out a medical problem. If no physical problem is found, then consider consulting a counselor or therapist to help you deal with your possible mood disorder. Your doctor can usually make a good referral to a competent therapist. Other sources might include trusted friends who have used counseling.

Some people with such conditions may be on medication. Unfortunately, as you’ll learn on the next page, these controlled substances can cause insomnia, too.

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Insomnia and Controlled Substances

A wide range of controlled substances, from legitimate to unhealthy, can cause insomnia.

Medication Side Effects

Sleep disruptions can also be caused by medications. If you are taking steroids, chemotherapy agents, diuretics, appetite suppressants, or drugs for allergies, pain, asthma, a heart condition, or Parkinson's disease, read the package insert or talk with your pharmacist about possible sleep disturbances that might occur.

Some medications cause you to feel drowsy, while others tend to keep you awake. There are also medications that, when taken alone, have no effect on your sleep, but when used with other medications, can cause sleep problems. If you suspect that any over-the-counter or prescription medication you are taking is cutting into your sleep time, talk with your doctor or pharmacist.

Caffeine

Everyone knows that coffee contains caffeine, which can help you wake up in the morning or stay awake when you feel like sleeping. Some people drink coffee not only upon waking but to keep themselves going throughout the day. There's no harm in one or two cups of coffee in the morning. And there are rare individuals who can drink coffee all day long without having it disturb their sleep.

But for most people, slugging down coffee all day more likely suggests that they're trying to combat sleepiness or have a bad caffeine habit. If you're sleeping well at night and function well during the day, you probably don't need to adjust your caffeine intake. But if you're having trouble sleeping at night, you should try cutting back.

Likewise, if you can fall asleep despite an evening cup of coffee but have to drag yourself through the day using a coffee crutch, you are probably too tired. All that caffeine can actually make your sleep lighter than what your body needs to feel its best. So, do yourself a favor and limit your caffeine intake.

People who overuse caffeine build up a tolerance over time, so that more is needed to sustain wakefulness. But a higher tolerance doesn't blunt the sleep-disturbing effects of caffeine on the body.

At a minimum, try to avoid caffeine for at least six hours before going to bed. Be aware, too, that caffeine is also found in regular tea, soft drinks, chocolate, and some over-the-counter medications. Some have enough caffeine to affect sleep.

Tobacco

Smoking cigarettes not only contributes to a number of diseases, it also keeps you awake. Studies show heavy smokers are at greater risk of insomnia than nonsmokers. It takes smokers longer to fall asleep, and they awaken more during the night. Indeed, coughing has been shown to be one of the main causes of sleep disturbance. Also, if withdrawal symptoms kick in a couple hours after your last cigarette, you might get up at 2 a.m. searching for another smoke.

Even people who smoke an average of one pack or less a day are awake a larger percentage of the night than nonsmokers.

If you decide to quit smoking, you may have trouble sleeping at first. But don't let this deter you from kicking the habit. A regular sleep schedule, a proper diet, exercise, and stress reduction can help you cope with quitting as well as help you get a good night's sleep. You may also want to speak to your doctor about getting help to quit.

Alcohol

Alcohol is possibly the drug most commonly used to promote drowsiness and enhance sleep, even more than prescription and over-the-counter remedies. It's true that alcohol may help you fall asleep more quickly, but the effects of alcohol do not last beyond the first few hours of the night. After that time your body experiences what is called withdrawal insomnia, and your sleep is poor during the second half of the night.

Using alcohol as a sleeping aid can lead to other problems, including alcohol overuse or even alcoholism. The process may begin innocently enough--say, with a glass of wine in the evening. But because the alcohol actually causes awakenings during the night, there is a tendency to drink more to suppress these later awakenings. The increased alcohol consumption further disturbs sleep, and a vicious cycle of worsening sleep and more drinking occurs. Over time, a problem with alcohol may develop.

Drinking can also affect a sleeper's breathing. Alcohol consistently makes snoring louder and may cause short pauses in breathing that awaken the sleeper. In a person with sleep apnea, who already has many such pauses during the night, alcohol causes the pauses to become longer and more frequent, and therefore, more dangerous.

In contrast to these controlled substances, on the next page, learn how something as natural as circadian rhythms can affect sleep.

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Circadian Rhythm Disorders and Insomnia

Circadian rhythms are the body’s mechanism for setting a schedule. The body has a sort of internal circadian pacemaker, or clock, centered in the brain. This clock governs things like appetite and sleep, taking cues from things like sunlight and darkness. The brain likes to keep to a schedule based on this clock.

But what if your lifestyle is out of sync with your body clock? What if you need to be awake and working when your brain is telling your body to sleep? Some sleep disruptions can be traced to the clash between body clock and lifestyle. These secondary sleep disorders are called circadian rhythm disorders. Two of the most common examples of circadian rhythm disorders are jet lag and night-shift work.

A good way to understand how "stubborn" the body clock can be and how difficult it can be to adjust it is to realize that the clock also affects behaviors such as eating. Just because you all of a sudden change the hours at which you eat doesn't mean your body will automatically feel hungry at the new times. Likewise, just because you switch from a day job to a job that keeps you working until 2 a.m. doesn't mean your body will automatically adjust to your new bedtime or wake-up time.

Your circadian clock can be adjusted somewhat, but it generally takes time and consistency. If you change your bedtime, your body will likely adjust eventually, but only if you consistently stick to the new bedtime and waking time. In addition, the body seems to adjust better if the bedtime is moved later rather than earlier. As you'll learn shortly, this seems to be why, when you're traveling through time zones, it's easier to adjust if you're moving east to west rather than west to east.

Treating circadian rhythm disorders often involves a combination of chronotherapy (gradually moving the bedtime up or back) and light therapy (exposing yourself to sunlight to reset the body clock and reinforce awake time). For example, if your body wants you to sleep late in the morning but your boss doesn't, try gradually moving your bedtime up and exposing yourself to bright sunlight in the early morning to help reset your sleep-wake cycle.

Jet lag is a particularly stubborn cause of insomnia. Learn how to overcome it on the next page. 

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Jet Lag and Insomnia

Those who travel know how skipping across time zones can play havoc with sleep patterns. Despite the myriad tips and techniques that float around about preventing jet lag, the only sure way to combat it is to begin adjusting your biological clock before leaving on your trip. This means gradually altering your sleep-wake schedule. But it definitely works.

First, you must determine whether your destination is ahead or behind your sleep schedule. If you lived in New York, for instance, and were traveling to London, your destination would be five hours ahead. If you lived in New York and were to fly to San Francisco, your destination would be three hours behind. So here's the formula: Start adjusting your sleep-wake schedule several days in advance of your trip to match the number of time zones you are crossing.

For instance, if London is your destination, and your normal bedtime in New York is midnight, you must begin going to bed earlier each night to adjust your sleep-wake schedule. Say you have five days before your trip and you make an effort to retire progressively earlier each night. By the day of your departure you are going to bed at 9:00 p.m. instead of midnight. This means you've already helped your body clock adjust to three of the five hours of difference. You would most likely adjust quickly to the two-hour difference that remains.

Research shows that for every time zone you cross, it takes a little less than a day to adjust your body clock. So every effort you make to alter your sleep-wake schedule prior to leaving helps.

In preparation for your return trip, you simply apply the same principle but in reverse, going to bed later rather than earlier. It's well known among seasoned travelers that journeying east to west seems to be an easier adjustment for most people than going west to east.

Unfortunately, for those traveling across more than six time zones, this process becomes hard to apply. You can only adjust your sleep schedule so much before it becomes burdensome in other ways. In these situations, shift as many sleep-wake hours as is practical prior to your departure. When you arrive at your destination, immediately begin operating on local time; that is, sleep at night and be up and active during the day.

While you will probably experience some of the symptoms of jet lag for at least several days, you will be better off than if you hadn't made any prior adjustment at all. Another wise move, no matter which direction you're traveling, is to make sure you get a couple of good nights of sleep before your departure.

Night-shift work can also wreak havoc on your sleeping schedule. Find out how to overcome insomnia while working at night on the next page.

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Night Shifts and Insomnia

Night-shift work can cause insomnia by making it nearly impossible to sleep on a consistent schedule. Here’s how:

Bill works the night shift most of the time at the local plastics manufacturing plant. He starts work at 11 p.m. and gets off at 7 a.m., five days a week. On workdays he tries to sleep until about 3 p.m., but there always seem to be things that disrupt his sleep, so he feels tired a lot. On weekends, because he wants to spend time with his family, he attempts to sleep on their schedule, which doesn't work very well for him. Bill's body clock can't make any permanent adjustments because he is always switching his sleep between days and nights.

Shift work does not come naturally to us. Our bodies are designed to work in the daylight and on a consistent schedule. Working on artificial schedules with nighttime hours has consequences. These people tend to sleep poorly and have decreased alertness during waking hours. They also have more accidents, work less efficiently, and have increased stress at home.

Unfortunately, there is no perfect solution for people who regularly work the night shift, but here are some tips that might help:

  • Choose a time for sleep that minimizes the separation between you and your family. And set aside some time each day to spend with your spouse and/or kids.
  • Once you decide when you will sleep, keep that time as consistent as possible--even on weekends or other days off.
  • Plan errands ahead, so they don't interfere with sleep. For example, if you sleep right after work, use a bank that has evening hours.
  • As a rule, limit sleep to one long block, rather than getting a shorter block with later naps.
  • Minimize daytime disturbances from phones, doorbells, and other sources. If necessary, get a pager that your family can use to contact you in an emergency.
  • Block outside noise by using a white-noise machine and by wearing a pair of soft ear-plugs.
  • Block out sunlight from the bedroom or use eye shades, and avoid exposure to daylight as much as possible during your sleep time.
  • Consider using the type of bright-light machine used to treat seasonal affective disorder (SAD) during your waking hours.

By following these suggestions, you can ease the toll the night shift takes on you and your family. For even better information, you could talk to a specialist. The next page explains who will be able to help you, and how.

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Getting Help for Insomnia

To get help for your insomnia, you should consult your doctor. In turn, your doctor may provide a referral to a sleep specialist or sleep clinic.

Prior to your first appointment with a sleep specialist, you will probably be asked to fill out a sleep questionnaire and complete a sleep log. At the first visit, the sleep specialist will review these and ask you a number of questions to try to understand the physical, psychological and social issues that might be part of your sleep problem.

To diagnose certain sleep disorders, such as narcolepsy, the sleep specialist may perform tests or arrange for you to sleep overnight in the sleep lab so your sleep patterns can be monitored. Once a diagnosis has been made, the sleep specialist may discuss the findings and possible treatments with you or may relay that information to your regular doctor so that together you and your doctor can consider appropriate treatment options.

Insomnia can seriously reduce your quality of life. Now you know where to turn for help, and using this article to help determine what's causing your insomnia, you'll be one step closer to getting a good night's sleep.

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ABOUT THE AUTHOR

Virgil D. Wooten, M.D., is the medical director of the TriHealth Sleep Centers at Good Samaritan and Bethesda North hospitals in Cincinnati. He is also a diplomat of the American Board of Sleep Medicine, a fellow of the American Academy of Sleep Medicine, and a consultant, writer, and speaker on sleep-related subjects. Dr. Wooten has more than 25 years of research, clinical and teaching experience.