Chapter One: Introduction

CHAPTER ONE: INTRODUCTION

1. Introduction

1.1 Insomnia

Insomnia is a common sleep condition characterized by difficulty falling asleep, remaining

asleep, or getting restorative sleep despite having enough time to do so. This disorder can cause
major daytime deficits, such as weariness, mood swings, and cognitive problems. Sleep is key
for general health and well-being; thus, proper insomnia management is critical for improving
quality of life and avoiding long-term health implications. This disorder can have a substantial
influence on a person's quality of life, causing daily weariness, mood swings, and reduced
cognitive functioning. Insomnia can be acute, lasting for a short time, or persistent, lasting three
months or more (Roth et al., 2007).

1.2 Types of Insomnia

Insomnia can be classified by following bases –

1. Based on Duration
2. Based on Cause
3. Based on Specific pattern
4. Based on Severity
5. Other Types of Insomnia

Based on Duration: Insomnia can be classified into two major types based on duration –

➢ Acute Insomnia: Acute insomnia is a short-term sleep disorder lasting from a few days
to a few weeks, often triggered by stress, major life changes, or emotional distress. It
involves difficulty falling asleep, frequent nighttime awakenings, or waking up too
early, leading to daytime fatigue, irritability, and reduced concentration. Unlike chronic
insomnia, which is long-lasting, acute insomnia typically resolves once the underlying
stressor is addressed. Adopting good sleep hygiene practices-such as maintaining a
regular sleep schedule, creating a comfortable sleep environment, and avoiding
stimulants before bed—can help alleviate symptoms and promote better sleep.
➢ Chronic Insomnia: Chronic insomnia is a persistent sleep disorder characterized by
difficulty falling asleep, staying asleep, or achieving restorative sleep, occurring at least
three times a week for three months or longer. It often results from underlying

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conditions such as anxiety, depression, chronic stress, or medical issues. Symptoms

include daytime fatigue, irritability, mood disturbances, and impaired cognitive
function, significantly impacting daily life. Treatment typically involves addressing
underlying causes, cognitive behavioral therapy for insomnia (CBT-I), and sometimes
medication. Adopting good sleep hygiene practices, such as maintaining a consistent
sleep schedule and creating a relaxing bedtime routine, can also help manage chronic
insomnia.

Based on Cause: Insomnia can be classified into two types based on cause –

➢ Primary Insomnia: Primary insomnia is a sleep disorder not directly caused by other
medical, psychiatric, or environmental conditions. It involves persistent difficulty
falling asleep, staying asleep, or experiencing restful sleep, lasting for at least one
month. Individuals with primary insomnia often experience daytime fatigue, mood
disturbances, and impaired concentration. The exact causes are often unclear, but stress,
lifestyle factors, and genetic predisposition may contribute. Treatment typically focuses
on cognitive behavioral therapy for insomnia (CBT-I), sleep hygiene education, and
sometimes medication. Strategies like maintaining a regular sleep schedule, creating a
comfortable sleep environment, and reducing caffeine intake can help alleviate
symptoms.
➢ Secondary Insomnia: Secondary insomnia is a sleep disorder resulting from
underlying conditions such as medical issues, psychiatric disorders, medications, or
substance use. Unlike primary insomnia, it is directly linked to another identifiable
cause. Symptoms include difficulty falling asleep, staying asleep, or achieving restful
sleep, leading to daytime fatigue and impaired functioning. Treatment focuses on
addressing the root cause, such as managing the medical condition, adjusting
medications, or treating mental health issues. In addition, adopting good sleep hygiene
practices—such as maintaining a consistent sleep schedule, creating a conducive sleep
environment, and avoiding stimulants—can help improve sleep quality and alleviate
symptoms.

Based on Specific pattern: Insomnia can be classified into following types based on pattern
–

➢ Sleep-Onset Insomnia: Sleep-onset insomnia is a sleep disorder characterized by

difficulty falling asleep at the beginning of the night. Individuals with this condition

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often lie awake for extended periods before finally drifting off, leading to insufficient
sleep and daytime fatigue.
➢ Sleep-Maintenance Insomnia: Sleep-maintenance insomnia is a sleep disorder where
individuals have trouble staying asleep throughout the night, often experiencing
frequent awakenings or difficulty returning to sleep. It leads to fragmented sleep,
daytime fatigue, and impaired functioning. Causes may include medical conditions,
psychiatric disorders, medications, or lifestyle factors.
➢ Early Morning Awakening Insomnia: Early morning awakening insomnia is a sleep
disorder where individuals consistently wake up earlier than desired and find it difficult
to fall back asleep. It results in shortened sleep duration, daytime fatigue, and impaired
functioning. Causes can include depression, anxiety, stress, or certain medical
conditions.
➢ Mixed Insomnia: Mixed insomnia is a sleep disorder characterized by a combination
of difficulties falling asleep, staying asleep, and waking up too early. It leads to
fragmented sleep, daytime fatigue, and impaired functioning. Causes can include stress,
anxiety, depression, medical conditions, medications, or lifestyle factors.

Based on Severity: Insomnia can be classified into following types based on severity –

➢ Mild Insomnia: Mild insomnia involves occasional difficulty falling asleep or staying
asleep, lasting for a short duration and not significantly impacting daily functioning. It
may occur due to stress, lifestyle changes, or temporary disruptions in sleep patterns.
Management typically involves improving sleep hygiene and addressing underlying
stressors.
➢ Moderate Insomnia: Moderate insomnia entails frequent difficulty falling asleep or
staying asleep, leading to occasional daytime fatigue and impairment in daily activities.
It may result from underlying stress, anxiety, or lifestyle factors. Management involves
addressing contributing factors, adopting sleep hygiene practices, and sometimes
seeking professional intervention for effective treatment.
➢ Severe Insomnia: Severe insomnia involves persistent and severe difficulty falling
asleep or staying asleep, leading to significant daytime impairment and distress. It often
disrupts daily functioning, causing profound fatigue, mood disturbances, and cognitive
impairments. Treatment typically requires comprehensive evaluation, including
medical and psychological assessments, and may involve specialized interventions.

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Other types of Insomnia: Other types of Insomnia are –

➢ Paradoxical Insomnia: Paradoxical insomnia, also known as sleep state

misperception, is a sleep disorder where individuals significantly underestimate the
amount of sleep they get. Despite reporting severe insomnia symptoms, objective
measures such as polysomnography show normal sleep patterns. Treatment often
involves cognitive behavioral therapy for insomnia (CBT-I).
➢ Idiopathic Insomnia: Idiopathic insomnia is a rare and lifelong sleep disorder
characterized by persistent difficulty falling asleep or staying asleep without an
identifiable cause. It typically begins in childhood and persists into adulthood, causing
chronic sleep deprivation and daytime impairment. Treatment focuses on symptom
management and improving sleep hygiene.
➢ Behavioral Insomnia of Childhood: Behavioral insomnia of childhood is a common
sleep disorder in children, often caused by learned associations between bedtime and
wakefulness. It includes difficulties falling asleep, staying asleep, or resisting bedtime.
Treatment involves implementing behavioral interventions to establish healthy sleep
habits and address underlying factors contributing to sleep disturbances (Riemann et
al., 2022).

1.3 History of Insomnia

The history of insomnia spans centuries, with references dating back to ancient civilizations.
In ancient times, insomnia was often attributed to supernatural causes or spiritual unrest.
Ancient Egyptians, Greeks, and Romans documented sleep disturbances and explored remedies
ranging from herbal treatments to rituals invoking deities associated with sleep. Throughout
the Middle Ages and Renaissance, insomnia continued to be linked to supernatural beliefs, with
treatments incorporating elements of magic, prayer, and herbalism. It wasn't until the
emergence of the scientific revolution in the 17th century that more systematic approaches to
understanding sleep disorders began to develop.

In the 19th and 20th centuries, advancements in psychology and medicine led to a deeper
understanding of insomnia as a clinical condition. The advent of sleep laboratories and the
introduction of tools like polysomnography allowed researchers to study sleep patterns and
disorders in a more systematic manner. Today, insomnia is recognized as a complex disorder
influenced by a variety of factors, including lifestyle, environment, genetics, and mental health.
Treatment approaches range from behavioral therapies to pharmacological interventions, with

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ongoing research aiming to further elucidate the underlying mechanisms and improve
management strategies for this prevalent sleep disorder (Buysse et al., 2017).

1.4 Epidemiology of Insomnia

Insomnia is a prevalent sleep disorder worldwide, affecting people of all ages and backgrounds.
Its epidemiology varies depending on factors such as age, gender, geographic location, and
comorbid conditions. Generally, insomnia becomes more common with increasing age,
affecting around 30% of adults at some point in their lives. Women are more likely to
experience insomnia than men, with hormonal changes, pregnancy, and menopause
contributing to this difference. In terms of geographic distribution, insomnia rates may vary,
influenced by cultural factors, socioeconomic status, and access to healthcare. Insomnia often
occurs alongside other medical or psychiatric conditions, such as anxiety, depression, chronic
pain, or neurodegenerative diseases, further complicating its epidemiological profile. Between
10% and 30% of adults have insomnia at any given point in time and up to half of people have
insomnia each year, making it the most common sleep disorder. About 6% of people have
insomnia that is not due to another problem and lasts for more than a month. People over the
age of 65 are affected more often than younger people. Females are more often affected than
males. Insomnia is 40% more common in women than in men (Suh et al., 2018).

1.5 Pathophysiology of Insomnia

Insomnia is thought to be a disorder of hyperarousal experienced throughout the entire day.

This hyperarousal may exhibit itself as a state of hypervigilance during the day and difficulty
initiating and maintaining sleep at night. This arousal is currently explained by both cognitive
and physiological models of insomnia. The cognitive model suggests that worry and rumination
about life stresses disrupt sleep, creating acute episodes of insomnia, especially in initiating
sleep and returning to sleep after an awakening. Then, once an individual begins to experience
sleep difficulties, worry and rumination shift from life events to worries about sleep itself and
about the daytime consequences of not getting enough sleep. This negatively toned cognitive
activity is further fueled if a sleep-related threat is detected or a sleep deficit is perceived. In
tandem with cognitive approaches, another model of insomnia evolution posits that
hyperarousal is primarily caused by physiological or neurophysiologic processes.
Physiological arousal has been assessed using whole-body metabolic rate, heart rate variability,
neuroendocrine markers, and functional neuroimaging. Oxygen consumption (VO2) can be
used to measure the whole-body metabolic rate. Recent research contrasted good sleepers to

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people with insomnia. Insomnia patients had significantly greater metabolic rates (measured at
intervals throughout the 24-hour day) than healthy controls. (Grewal & Doghramji, 2017) Heart
rate variability, which is governed by both sympathetic and parasympathetic nervous system
processes, may serve as a marker of arousal. The neuroendocrine system may also provide
evidence of arousal as demonstrated by chronic activation of the stress response system.
Several studies measuring 24-hour urinary free cortisol excretion have found high levels in
poor sleepers. Urinary free cortisol levels have also been positively correlated with total wake
time, and urinary catecholamines have been correlated with stage 1 sleep percentage and wake
time after sleep onset.38,40 Plasma measures of cortisol and adrenocorticotropic hormone
(ACTH) have been evaluated in insomnia patients and healthy normal sleepers. Although the
evidence is somewhat mixed, primary insomniacs appear to have higher levels of these
compounds in their plasma, with the most significant differences seen in the evening and the
first half of the night. Both the urinary and plasma measures of cortisol and ACTH suggest that
the HPA axis is associated with the pathology of chronic insomnia. Patients with insomnia had
higher cerebral glucose metabolism than healthy subjects during waking and non-rapid eye
movement (REM) sleep stages. Furthermore, insomnia patients showed smaller decreases in
relative metabolism from waking to non-REM sleep in wake-promoting areas of the brain.
These findings point to interconnected brain networks involved in the inability to fall asleep,
including a general arousal system, an emotion-regulating system, and a cognitive system (Suh
et al., 2018).

1.6 Causes of Insomnia

Symptoms of insomnia can be caused by or be associated with:

✓ Sleep breathing disorders, such as sleep apnea or upper airway resistance syndrome
✓ Use of psychoactive drugs (such as stimulants), including certain medications, herbs,
caffeine, nicotine, cocaine, amphetamines, methylphenidate, aripiprazole, MDMA,
modafinil, or excessive alcohol intake
✓ Use of or withdrawal from alcohol and other sedatives, such as anti-anxiety and sleep
drugs like benzodiazepines
✓ Use of or withdrawal from pain-relievers such as opioids
✓ Heart disease

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✓ Restless legs syndrome, which can cause sleep onset insomnia due to the discomforting
sensations felt and the need to move the legs or other body parts to relieve these
sensations
✓ Periodic limb movement disorder (PLMD), which occurs during sleep and can cause
arousals of which the sleeper is unaware
✓ Pain: an injury or condition that causes pain can preclude an individual from finding a
comfortable position in which to fall asleep and can also cause awakening.
✓ Hormone shifts such as those that precede menstruation and those during menopause
✓ Life events such as fear, stress, anxiety, emotional or mental tension, work problems,
financial stress, birth of a child, and bereavement
✓ Gastrointestinal issues such as heartburn or constipation
✓ Mental, neurobehavioral, or neurodevelopmental disorders such as bipolar disorder,
clinical depression, generalized anxiety disorder, post-traumatic stress disorder,
schizophrenia, obsessive compulsive disorder, autism, dementia.
✓ Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an
inability to sleep at some times of the day and excessive sleepiness at other times of the
day. Chronic circadian rhythm disorders are characterized by similar symptoms.
✓ Certain neurological disorders such as brain lesions, or a history of traumatic brain
injury
✓ Medical conditions such as hyperthyroidism
✓ Abuse of over the counter or prescription sleep aids (sedative or depressant drugs) can
produce rebound insomnia
✓ Poor sleep hygiene, e.g., noise or over-consumption of caffeine
✓ A rare genetic condition can cause a prion-based, permanent and eventually fatal form
of insomnia called fatal familial insomnia
✓ Physical exercise: exercise-induced insomnia is common in athletes in the form of
prolonged sleep onset latency
✓ Increased exposure to the blue light from artificial sources, such as phones or computers
✓ Chronic pain
✓ Lower back pain
✓ Asthma

Sleep studies using polysomnography have suggested that people who have sleep disruption
have elevated night-time levels of circulating cortisol and adrenocorticotropic hormone. They

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also have an elevated metabolic rate, which does not occur in people who do not have insomnia
but whose sleep is intentionally disrupted during a sleep study. Studies of brain metabolism
using positron emission tomography (PET) scans indicate that people with insomnia have
higher metabolic rates by night and by day. The question remains whether these changes are
the causes or consequences of long-term insomnia (Araújo et al., 2017).

1.7 Risk Factors of Insomnia

Insomnia affects people of all age groups but people in the following groups have a higher
chance of acquiring insomnia:

o Individuals older than 60: People who are aged over 60 may face insomnia because
at this stage of life they have no work to do. Without doing any work, they become idle
and weak. Besides, they face a lot of diseases like blood pressure, diabetes etc. For all
this purpose, Age can be a major risk factor of Insomnia.
o History of mental health disorders: History of Mental health disorders including
depression, etc. can be a risk factor for primary and secondary insomnia.
o Emotional stress: Emotional stress is one of the major risk factors of Insomnia.
Basically, Emotional stress occurs when people face work pressure, family problems,
relationship failure, and unsuccessful in work and personal life. Emotional stress can
push a person to chronic insomnia.
o Working late night shifts: People who are used to doing night shift work or late-night
work must face the problem of severe insomnia. Now-a-days, people are addicted to
cell phones and use social media late at night that also may create insomnia.
o Traveling through different time zones: By travelling from one time zone to another
time zone also make primary Insomnia. Due to different timing of sleeping can occur
insomnia.
o Having chronic diseases: Chronic diseases like diabetes, kidney disease, lung disease,
Alzheimer's, or heart disease, can be a major risk factor of Insomnia.
o Alcohol or drug use disorders: Using drug or having alcohol regularly, can be the risk
factor of Insomnia.
o Gastrointestinal reflux disease: Gastrointestinal reflux also may be one of the risk
factors of Insomnia.
o Heavy smoking: Too much smoking can be the risk factor of Insomnia. Over nicotine
can be the reason behind the scenario.

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o Work stress: Overloaded work stress also may be the risk factor of Insomnia for
individuals.
o Individuals of low SES: People with lower income or low socioeconomic status (SES)
can face insomnia for having too much stress in their personal and social life.
o Household stress: Household stress like family income, work, children education etc.
can be one of the major risk factors for Insomnia (Brownlow et al., 2020).

1.8 Signs and symptoms of Insomnia

Symptoms of insomnia:

o Difficulty falling asleep, including difficulty finding a comfortable sleeping position

o Waking during the night, being unable to return to sleep and waking up early
o Not able to focus on daily tasks, difficulty in remembering
o Daytime sleepiness, irritability, depression or anxiety
o Feeling tired or having low energy during the day
o Trouble concentrating
o Being irritable, acting aggressive or impulsive

Sleep onset insomnia is difficult falling asleep at the beginning of the night, often a symptom
of anxiety disorders. Delayed sleep phase disorder can be misdiagnosed as insomnia, as sleep
onset is delayed to much later than normal while awakening spills over into daylight hours.

It is common for patients who have difficulty falling asleep to also have nocturnal awakenings
with difficulty returning to sleep. Two-thirds of these patients wake up in the middle of the
night, with more than half having trouble falling back to sleep after a middle-of-the-night
awakening.

Early morning awakening is an awakening occurring earlier (more than 30 minutes) than
desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early
morning awakening is often a characteristic of depression. Anxiety symptoms may well lead
to insomnia. Some of these symptoms include tension, compulsive worrying about the future,
feeling overstimulated, and overanalyzing past events (Krystal et al., 2019).

1.9 Prevalence of Insomnia

Estimates of the prevalence of insomnia depend on the criteria used to define insomnia and
more importantly the population studied. A consensus has developed from population-based

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studies that approximately 30% of a variety of adult samples drawn from different countries
report one or more of the symptoms of insomnia: difficulty initiating sleep, difficulty
maintaining sleep, waking up too early, and in some cases, nonrestorative or poor quality of
sleep. Conclusions from the NIH State-of-the-Science Conference held in June 2005 indicate
that the addition of a diagnostic requirement that includes perceived daytime impairment or
distress as a function of the insomnia symptoms results in approximately 10% prevalence of
insomnia. Finally, the application of more stringent diagnostic criteria, such as the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which includes the
additional requirements that insomnia symptoms persist for at least 1 month and do not
exclusively occur in the presence of another sleep disorder, mental disorder, or the direct
physiological effects of a substance or medical condition, yields current prevalence estimates
of approximately 6%.

Several well-identified risk factors for insomnia were reported by the State-of-the-Science
Conference in June 2005. Age and gender are the most clearly identified demographic risk
factors, with an increased prevalence in women and older adults. While the cause of this
increased risk in the elderly is not well defined, it may be due to the partial decline in
functionality of sleep control systems that may contribute to insomnia in this older population.
Importantly, the presence of comorbid medical conditions is also a significant contributor to
the increased prevalence of insomnia in the elderly. Additionally, in women, insomnia is more
prevalent with both the onset of menses and menopause. Comorbid medical disorders,
psychiatric disorders, and working night or rotating shifts all represent significant risks for
insomnia. It is important to recognize that these factors do not independently cause insomnia,
but rather they are precipitants of insomnia in individuals predisposed to this disorder. In fact,
chronic illnesses are a significant risk for insomnia. It is estimated that the majority of people
with insomnia (approximately 75%–90%) have an increased risk for comorbid medical
disorders, such as conditions causing hypoxemia and dyspnea, gastroesophageal reflux disease,
pain conditions, and neurodegenerative diseases. Importantly, a variety of primary sleep
disorders as well as circadian rhythm disorders are frequently comorbid with and often lead to
insomnia. Among the primary sleep disorders, restless legs syndrome (RLS), periodic limb
movement disorders (PLMD), and sleep-related breathing disorders (snoring, dyspnea, sleep
apnea) often present with insomnia symptoms. This is especially true among the elderly.
Among younger individuals, difficulty falling asleep is often associated with phase delay
syndrome. However, in the elderly, phase advance syndrome results in reports of difficulty

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initiating sleep, maintaining sleep, and experiencing early morning awakenings. The most
common comorbidities associated with insomnia are psychiatric disorders. It is estimated that
40% of all insomnia patients have a coexisting psychiatric condition. Among these psychiatric
disorders, depression is the most common, and insomnia is a diagnostic symptom for
depression and anxiety disorders (Roth et al., 2007).

1.10 Diagnosis of Insomnia

In medicine, insomnia is widely measured using the Athens insomnia scale. It is measured
using eight different parameters related to sleep, finally represented as an overall scale which
assesses an individual's sleep pattern. A qualified sleep specialist should be consulted for the
diagnosis of any sleep disorder so the appropriate measures can be taken. Past medical history
and physical examinations need to be done to eliminate other conditions that could be the cause
of insomnia. After all other conditions are ruled out, a comprehensive sleep history should be
taken. The sleep history should include sleep habits, medications (prescription and non-
prescription), alcohol consumption, nicotine and caffeine intake, co-morbid illnesses, and sleep
environment. A sleep diary can be used to keep track of the individual's sleep patterns. The
diary should include time to bed, total sleep time, time to sleep onset, number of awakenings,
use of medications, time of awakening, and subjective feelings in the morning. The sleep diary
can be replaced or validated using out-patient actigraphy for a week or more, using a non-
invasive device that measures movement. Workers who complain of insomnia should not
routinely have polysomnography to screen for sleep disorders. This test may be indicated for
patients with symptoms in addition to insomnia, including sleep apnea, obesity, a thick neck
diameter, or high-risk fullness of the flesh in the oropharynx. Usually, the test is not needed to
make a diagnosis, and insomnia, especially for working people, can often be treated by
changing a job schedule to make time for sufficient sleep and by improving sleep hygiene
(Nunes & Bruni et al., 2015).

Some patients may need to do an overnight sleep study to determine if insomnia is present.
Such a study will commonly involve assessment tools including a polysomnogram and the
multiple sleep latency test. Specialists in sleep medicine are qualified to diagnose disorders
within the, according to the ICSD, 81 major sleep disorder diagnostic categories. Patients with
some disorders, including delayed sleep phase disorder, are often mis-diagnosed with primary
insomnia; when a person has trouble getting to sleep and awakening at desired times, but has
a normal sleep pattern once asleep, a circadian rhythm disorder is a likely cause.

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In many cases, insomnia is co-morbid with another disease, side-effects from medications, or
a psychological problem. Approximately half of all diagnosed insomnia is related to psychiatric
disorders. For those who have depression, "insomnia should be regarded as a co-morbid
condition, rather than as a secondary one;" insomnia typically predates psychiatric symptoms.
"In fact, it is possible that insomnia represents a significant risk for the development of a
subsequent psychiatric disorder." Insomnia occurs in between 60% and 80% of people with
depression. This may partly be due to treatment used for depression (de Zambotti et al., 2018).

1.11 Management of Insomnia

It is recommended to rule out medical and psychological causes before deciding on the
treatment for insomnia. Cognitive behavioral therapy is generally the first line treatment once
this has been done. It has been found to be effective for chronic insomnia. The beneficial
effects, in contrast to those produced by medications, may last well beyond the stopping of
therapy (Chan et al., 2021).

Non-medication Based

Non-medication-based strategies have comparable efficacy to hypnotic medication for

insomnia and they may have longer lasting effects. Hypnotic medication is only recommended
for short-term use because dependence with rebound withdrawal effects upon discontinuation
or tolerance can develop.

Non-medication-based strategies provide long lasting improvements to insomnia and are

recommended as a first line and long-term strategy of management. Behavioral sleep medicine
(BSM) tries to address insomnia with non-pharmacological treatments. The BSM strategies
used to address chronic insomnia include attention to sleep hygiene, stimulus control,
behavioral interventions, sleep-restriction therapy, paradoxical intention, patient education, and
relaxation therapy. Some examples are keeping a journal, restricting the time spent awake in
bed, practicing relaxation techniques, and maintaining a regular sleep schedule and a wake-up
time. Behavioral therapy can assist a patient in developing new sleep behaviors to improve
sleep quality and consolidation. Behavioral therapy may include learning healthy sleep habits
to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies
and regulating the circadian clock.

Music may improve insomnia in adults (see music and sleep). EEG biofeedback has
demonstrated effectiveness in the treatment of insomnia with improvements in duration as well

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as quality of sleep. Self-help therapy (defined as a psychological therapy that can be worked
through on one's own) may improve sleep quality for adults with insomnia to a small or
moderate degree.

Stimulus control therapy is a treatment for patients who have conditioned themselves to
associate the bed, or sleep in general, with a negative response. As stimulus control therapy
involves taking steps to control the sleep environment, it is sometimes referred interchangeably
with the concept of sleep hygiene. Examples of such environmental modifications include
using the bed for sleep and sex only, not for activities such as reading or watching television;
waking up at the same time every morning, including on weekends; going to bed only when
sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning
an activity in another location if sleep does not occur in a reasonably brief period of time after
getting into bed (commonly ~20 min); reducing the subjective effort and energy expended
trying to fall asleep; avoiding exposure to bright light during night-time hours, and eliminating
daytime naps.

Paradoxical intention is a cognitive reframing technique where the insomniac, instead of

attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying
to fall asleep). One theory that may explain the effectiveness of this method is that by not
voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the
need or requirement to fall asleep, which is meant to be a passive act. This technique has been
shown to reduce sleep effort and performance anxiety and lower subjective assessment of
sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs)
(Maness & Khan et al., 2015).

• Sleep hygiene: Sleep hygiene is a common term for all the behaviors which relate to
the promotion of good sleep. They include habits which provide a good foundation for
sleep and help to prevent insomnia. However, sleep hygiene alone may not be adequate
to address chronic insomnia. Sleep hygiene recommendations are typically included as
one component of cognitive behavioral therapy for insomnia (CBT-I).
Recommendations include reducing caffeine, nicotine, and alcohol consumption,
maximizing the regularity and efficiency of sleep episodes, minimizing medication
usage and daytime napping, the promotion of regular exercise, and the facilitation of a
positive sleep environment. The creation of a positive sleep environment may also be
helpful in reducing the symptoms of insomnia. On the other hand, a systematic review

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by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia
due to the evidence of absence of its efficacy and potential delaying of adequate
treatment, recommending instead that effective therapies such as CBT-I should be
preferred.
• Cognitive behavioral therapy: There is some evidence that cognitive behavioral
therapy for insomnia (CBT-I) is superior in the long-term to benzodiazepines and the
nonbenzodiazepines in the treatment and management of insomnia. In this therapy,
patients are taught improved sleep habits and relieved of counter-productive
assumptions about sleep. Common misconceptions and expectations that can be
modified include:
o Unrealistic sleep expectations.
o Misconceptions about insomnia causes.
o Amplifying the consequences of insomnia.
o Performance anxiety after trying for so long to have a good night's sleep by
controlling the sleep process.
Numerous studies have reported positive outcomes of combining cognitive behavioral
therapy for insomnia treatment with treatments such as stimulus control and relaxation
therapies. Hypnotic medications are equally effective in the short-term treatment of
insomnia, but their effects wear off over time due to tolerance. The effects of CBT-I
have sustained and lasting effects on treating insomnia long after therapy has been
discontinued. The addition of hypnotic medications with CBT-I adds no benefit in
insomnia. The long-lasting benefits of a course of CBT-I shows superiority over
pharmacological hypnotic drugs. Even in the short term when compared to short-term
hypnotic medication such as zolpidem, CBT-I still shows significant superiority. Thus
CBT-I is recommended as a first line treatment for insomnia.
• Acceptance and commitment therapy: Treatments based on the principles of
acceptance and commitment therapy (ACT) and metacognition have emerged as
alternative approaches to treating insomnia. ACT rejects the idea that behavioral
changes can help insomniacs achieve better sleep, since they require "sleep efforts" -
actions which create more "struggle" and arouse the nervous system, leading to
hyperarousal. The ACT approach posits that acceptance of the negative feelings
associated with insomnia can, in time, create the right conditions for sleep. Mindfulness
practice is a key feature of this approach, although mindfulness is not practiced

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inducing sleep (this is a sleep effort to be avoided) but rather as a longer-term activity
to help calm the nervous system and create the internal conditions from which sleep
can emerge (Bollu & Kaur et al., 2019).

Medication Based: Many people with insomnia use sleeping tablets and other sedatives. In
some places medications are prescribed in over 95% of cases. They, however, are a second line
treatment. In 2019, the US Food and Drug Administration stated it is going to require warnings
for eszopiclone, zaleplon, and zolpidem, due to concerns about serious injuries resulting from
abnormal sleep behaviors, including sleepwalking or driving a vehicle while asleep (Neubauer
et al., 2018).

• Antihistamines: As an alternative to taking prescription drugs, some evidence shows

that an average person seeking short-term help may find relief by taking over-the-
counter antihistamines such as diphenhydramine or doxylamine. Diphenhydramine and
doxylamine are widely used in nonprescription sleep aids. Antihistamine effectiveness
for sleep may decrease over time, and anticholinergic side-effects (such as dry mouth)
may also be a drawback with these particular drugs. While addiction does not seem to
be an issue with this class of drugs, they can induce dependence and rebound effects
upon abrupt cessation of use.
• Antidepressants: While insomnia is a common symptom of depression,
antidepressants are effective for treating sleep problems whether they are associated
with depression. While all antidepressants help regulate sleep, some antidepressants,
such as amitriptyline, doxepin, mirtazapine, trazodone, and trimipramine, can have an
immediate sedative effect, and are prescribed to treat insomnia. Trazodone was at the
beginning of the 2020s the biggest prescribed drug for sleep in the United States despite
not being indicated for sleep. Amitriptyline, doxepin, and trimipramine all have
antihistaminergic, anticholinergic, antiadrenergic, and antiserotonergic properties,
which contribute to both their therapeutic effects and side effect profiles, while
mirtazapine's actions are primarily antihistaminergic and antiserotonergic and
trazodone's effects are primarily antiadrenergic and antiserotonergic. Mirtazapine is
known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep
efficiency and increasing the total amount of sleeping time in people with both
depression and insomnia (Everitt et al., 2018).

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• Melatonin agonists: Melatonin receptor agonists such as melatonin and ramelteon are
used in the treatment of insomnia. The evidence for melatonin in treating insomnia is
generally poor. There is low-quality evidence that it may speed the onset of sleep by 6
minutes. Ramelteon does not appear to speed the onset of sleep or the amount of sleep
a person gets. Usage of melatonin as a treatment for insomnia in adults has increased
from 0.4% between 1999 and 2000 to nearly 2.1% between 2017 and 2018. While the
use of melatonin in the short-term has been proven to be generally safe and it is shown
to not be a dependent medication, side effects can still occur.
• Benzodiazepines: The most commonly used class of hypnotics for insomnia are the
benzodiazepines. Benzodiazepines are not significantly better for insomnia than
antidepressants. Chronic users of hypnotic medications for insomnia do not have better
sleep than chronic insomniacs not taking medications. In fact, chronic users of hypnotic
medications have more regular night-time awakenings than insomniacs not taking
hypnotic medications. Many have concluded that these drugs cause an unjustifiable risk
to the individual and to public health and lack evidence of long-term effectiveness. It is
preferred that hypnotics be prescribed for only a few days at the lowest effective dose
and avoided altogether wherever possible, especially in the elderly (Lie et al., 2015).
• Z-Drugs: Nonbenzodiazepine or Z-drug sedative-hypnotic drugs, such as zolpidem,
zaleplon, zopiclone, and eszopiclone, are a class of hypnotic medications that are like
benzodiazepines in their mechanism of action and indicated for mild to moderate
insomnia. Their effectiveness at improving time to sleeping is slight, and they have
similar-though potentially less severe-side effect profiles compared to benzodiazepines.
• Orexin antagonists: Orexin receptor antagonists are a more recently introduced class
of sleep medications and include suvorexant, lemborexant, and daridorexant, all of
which are FDA-approved for treatment of insomnia characterized by difficulties with
sleep onset and/or sleep maintenance. They are oriented towards blocking signals in the
brain that stimulate wakefulness, therefore claiming to address insomnia without
creating dependence.
• Antipsychotics: Certain atypical antipsychotics, particularly quetiapine, olanzapine,
and risperidone, are used in the treatment of insomnia. However, while common, use
of antipsychotics for this indication is not recommended as the evidence does not
demonstrate a benefit, and the risk of adverse effects are significant. A major 2022

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 Chapter One: Introduction

systematic review and network meta-analysis of medications for insomnia in adults

found that quetiapine did not demonstrate any short-term benefits for insomnia.
• Other sedatives: Gabapentinoids like gabapentin and pregabalin have sleep-promoting
effects but are not commonly used for treatment of insomnia. Gabapentin is not
effective in helping alcohol related insomnia. Barbiturates, while once used, are no
longer recommended for insomnia due to the risk of addiction and other side effects.
• Alternative medicine: Herbal products, such as valerian, kava, chamomile, and
lavender, have been used to treat insomnia. However, there is no quality evidence that
they are effective and safe. The same is true for cannabis and cannabinoids. It is likewise
unclear whether acupuncture is useful in the treatment of insomnia (Asnis et al., 2015).

1.12 Prevention of Insomnia

Among lifestyle practices, going to sleep and waking up at the same time each day can create
a steady pattern which may help to prevent insomnia. Avoidance of vigorous exercise and
caffeinated drinks a few hours before going to sleep is recommended, while exercise earlier in
the day may be beneficial. Other practices to improve sleep hygiene may include:

➢ Avoiding or limiting naps

➢ Treating pain at bedtime
➢ Avoiding large meals, beverages, alcohol, and nicotine before bedtime
➢ Finding soothing ways to relax into sleep, including use of white noise
➢ Making the bedroom suitable for sleep by keeping it dark, cool, and free of devices,
such as clocks, cell phones, or televisions
➢ Maintain regular exercise
➢ Try relaxing activities before sleeping (Jarrin et al., 2018).

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References
Araújo, T., Jarrin, D. C., Leanza, Y., Vallières, A., & Morin, C. M. (2017). Qualitative studies
of insomnia: Current state of knowledge in the field. Sleep Medicine Reviews, 31, 58–69.

Asnis, G., Thomas, M., & Henderson, M. (2015). Pharmacotherapy Treatment Options for
Insomnia: A Primer for Clinicians. International Journal of Molecular Sciences, 17(1),
50.

Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri Medicine,
116(1), 68–75.

Brownlow, J. A., Miller, K. E., & Gehrman, P. R. (2020). Insomnia and Cognitive Performance.
Sleep Medicine Clinics, 15(1), 71–76.

Buysse, D. J., Rush, A. J., & Reynolds, C. F. (2017). Clinical Management of Insomnia
Disorder. JAMA, 318(20), 1973.

Chan, N. Y., Chan, J. W. Y., Li, S. X., & Wing, Y. K. (2021). Non-pharmacological Approaches
for Management of Insomnia. Neurotherapeutics, 18(1), 32–43.

de Zambotti, M., Goldstone, A., Colrain, I. M., & Baker, F. C. (2018). Insomnia disorder in
adolescence: Diagnosis, impact, and treatment. Sleep Medicine Reviews, 39, 12–24.

Everitt, H., Baldwin, D. S., Stuart, B., Lipinska, G., Mayers, A., Malizia, A. L., Manson, C. C.,
& Wilson, S. (2018). Antidepressants for insomnia in adults. Cochrane Database of
Systematic Reviews, 2018(5).

Grewal, R. G., & Doghramji, K. (2017). Epidemiology of Insomnia. In Clinical Handbook of

Insomnia (pp. 13–25). Springer International Publishing.

Jarrin, D. C., Alvaro, P. K., Bouchard, M.-A., Jarrin, S. D., Drake, C. L., & Morin, C. M. (2018).
Insomnia and hypertension: A systematic review. Sleep Medicine Reviews, 41, 3–38.

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of
insomnia: an update. World Psychiatry, 18(3), 337–352.

Lie, J. D., Tu, K. N., Shen, D. D., & Wong, B. M. (2015). Pharmacological Treatment of
Insomnia. P & T : A Peer-Reviewed Journal for Formulary Management, 40(11), 759–
771.

Literature Review on Insomnia 18

 Chapter One: Introduction

Maness, D. L., & Khan, M. (2015). Nonpharmacologic Management of Chronic Insomnia.

American Family Physician, 92(12), 1058–1064.

Neubauer, D. N., Pandi-Perumal, S. R., Spence, D. W., Buttoo, K., & Monti, J. M. (2018).
Pharmacotherapy of Insomnia. Journal of Central Nervous System Disease, 10,
117957351877067.

Nunes, M. L., & Bruni, O. (2015). Insomnia in childhood and adolescence: clinical aspects,
diagnosis, and therapeutic approach. Jornal de Pediatria, 91(6), S26–S35.

Riemann, D., Benz, F., Dressle, R. J., Espie, C. A., Johann, A. F., Blanken, T. F., Leerssen, J.,
Wassing, R., Henry, A. L., Kyle, S. D., Spiegelhalder, K., & Van Someren, E. J. W. (2022).
Insomnia disorder: State of the science and challenges for the future. Journal of Sleep
Research, 31(4).

Roth, T. (2007). Insomnia: definition, prevalence, etiology, and consequences. Journal of

Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep
Medicine, 3(5 Suppl), S7-10.

Suh, S., Cho, N., & Zhang, J. (2018). Sex Differences in Insomnia: from Epidemiology and
Etiology to Intervention. Current Psychiatry Reports, 20(9), 69.

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