Frequently Asked Questions

What is insomnia?

The American Academy of Sleep Medicine defines insomnia as, “…the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of day time impairment.” (Journal of Clinical Sleep Medicine, 2008, 4, 5, 487-503).

In practical terms, insomnia may be seen as ongoing struggles experienced at any point through the desired sleep period, whether at the beginning, in the middle, or at the end of the night. Short periods of sleep disruption are common and can occur for many reasons, such as seasonal factors like shifts in sunrise/sunset through the year and daylight saving time, travel across multiple time zones (jet lag), illness or injury with ensuing pain or discomfort, changes in the sleep environment (new bed, house guests, fireworks), or impactful serious stressors such as the experience of a traumatic accident, assault, and separation from or death of a loved one. Clinical insomnia is diagnosed when the sleep problems continue to persist past the expected time for return to a normal sleep pattern.

The DSM-5, a reference that medical and behavioral professionals use to identify and classify mental/emotional disorders, indicates that for insomnia to be formally diagnosed, the problem must cause significant impairment in functioning during waking hours, occur at least 3 nights a week, be present for at least 3 months, be present despite adequate opportunity to sleep, not be better explained by and not occur only during some other sleep-wake disorder (such as narcolepsy), not be attributable to the effects of a substance (recreational drugs or prescribed medications, and not be attributable primarily to some other mental disorder or medical condition (American Psychiatric Association. (2022). Sleep-Wake Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Types of insomnia

Insomnia can be classified in several different ways. The simplest is the differentiation between acute (short-term) and chronic insomnia. Beyond that, researchers and sleep experts describe variations in how insomnia presents as follows:

o Sleep Onset Insomnia – trouble initiating sleep at the beginning of the sleep cycle, lasting beyond 20 to 30 minutes. Individuals may experience tossing and turning, anxiety and frustration about lost sleep and how they will struggle the next day, physical tension, and high levels of “sleep effort.”

o Sleep Maintenance Insomnia – frequent and/or prolonged awakening through the night. This could range from waking once and being unable to return to sleep for a long period (30 minutes or more), or multiple awakenings, either of which reduces total sleep time in a way that significantly impacts daytime mental and physical functioning.

o Terminal Insomnia – while this sounds scary, it merely refers to problems waking up much earlier than desired and being unable to fall back asleep. Again, this early awakening is problematic when it does not allow for adequate sleep so that the individual feels rested and alert the next day.

o Mixed Insomnia – this can be thought of as a combination of any of the three types of insomnia mentioned above. How these various types of insomnia manifest themselves may change over time; for example, going through periods of difficulty initiating sleep, but then the problem shifting to awakening too early, etc. It can also describe experiencing any of the three types of insomnia (sleep onset, maintenance, terminal) simultaneously.

o Comorbid Insomnia – while in the past, sleep experts recognized that sleep difficulties often occurred due to or alongside other medical or mental health conditions (restless legs syndrome, gastrointestinal issues such GERD or ulcerative colitis, depression, anxiety, PTSD), research and clinical experience have shown that in many cases the effects can be bidirectional. Many medical and psychological conditions can cause or exacerbate insomnia, and the presence of insomnia can increase the severity of many of those physical and mental health problems as well. It can also be the case that even when these other conditions are resolved or become manageable, insomnia may continue. Whether insomnia is the cause or the effect of other disorders, effective treatment of insomnia can, in many cases, improve functioning and reduce the severity of co-occurring conditions.

What causes insomnia?

Insomnia can occur for a variety of reasons. Individuals may be genetically predisposed to be light sleepers, but then stressful life events may cause insomnia to manifest itself. These stressors can include any phenomena that causes a heightened state of physical and/or mental arousal, such as pain, hormonal changes, job stress, family or relationship conflict, financial difficulties, etc. For most people, once the stressor resolves or decreases sufficiently, better sleep comes. For some, however, these disruptions can trigger the development of chronic insomnia.

Other causes of insomnia can include shift work that disrupts the natural wake-sleep cycle in such a way that, even after ending swing or night shifts, the person is unable to re-establish a good sleep pattern. Highly disturbing events, single or multiple traumas such as those that can occur in combat, domestic violence, severe injury, or by witnessing horrific events or loss of life, may initiate acute insomnia. Sometimes insomnia may not become a problem until weeks, months, or even years have passed since those events.

There are some cases in which we are never able to determine the cause. Fortunately, the treatment can be highly effective whether we understand the root causes or not!

What are the medical and mental health risks of poor sleep?

While the human body is amazingly resilient and can function quite well without sufficient sleep for some time, eventually lack of sleep will take a toll on physical and mental functioning. Because sleep is necessary for body repair and restoration, insomnia can weaken the immune system, impair cellular repair, and affect health in many other ways. According to the National Institute of Health, “The cumulative long-term effects of sleep loss and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke.” (https://www.ncbi.nlm.nih.gov/books/NBK19961/). This paper also discusses research outlining other effects of sleep loss and sleep-related disorders including increased errors in judgment, heightened mortality, decreased performance in a number of areas, increased accidents and injuries, lower quality of life and decreased well-being, irritability and lower frustration tolerance. Clearly, loss of sleep is an important public health issue with both personal and societal effects.

What are the most effective treatments for insomnia?

Cognitive Behavior Therapy for Insomnia (CBT-I) has been considered the “gold standard” for treatment of insomnia for many years. It is primarily a “behavioral intervention” in that it addresses changes in behavior related to sleep that increase the likelihood that good sleep will follow. CBT-I may also include strategies that specifically address thoughts and beliefs that are believed to interfere with sleep or that create or increase mental arousal or alertness at bedtime, including worries, fears about not sleeping well, or difficulties quieting the “busy mind.”

Other non-pharmacological strategies to improve sleep include sleep hygiene therapy, relaxation training, and meditation, though generally these treatments are not sufficient or effective by themselves in resolving chronic insomnia.

How about medications for insomnia?

While medication may be the first thing many people think of when they have trouble sleeping for more than a night or two, there are important limitations and risks to consider before taking over-the-counter or prescription medications (also known as hypnotics or soporific drugs) for sleep. These include the potential for bothersome side effects, such as extended daytime drowsiness, dizziness, impaired focus and decreased alertness, headaches, digestive problems, dry mouth, and muscle weakness. Psychological dependence may also become a problem, even with medications that are not believed to be physically addictive, such that patients may develop a strong belief that they will not be able to sleep without the medication, which can induce anxiety that makes falling asleep even more difficult. Experts suggest that adults 65 or older avoid sleep aids altogether, as the side effects can be much greater, including the risks of falling and car accidents, as well as significant memory impairment. That said, for most adults, modern sleep medications prescribed by a knowledgeable physician may be quite helpful for short term treatment of acute insomnia.

What if I am taking a sleep medication already? Will I need to stop taking it to benefit from CBT-I?

Many patients referred for CBT-I have tried or are currently taking OTC or prescribed sleep medication. Use of these medications is not necessarily contraindicated while being treated with CBT-I but may reduce the effectiveness and longer-term benefit of this treatment. Many people seek alternatives to medication precisely because they find the side effects bothersome or because they do not wish to depend on medications that may not be necessary. When needed or when requested by the patient, Dr. Wyma is happy to consult with and work collaboratively with your prescribing physician where sleep medications, or any medications that may affect your sleep, are concerned. Many CBT-I patients have successfully reduced or eliminated their use of sleep medications during the course of treatment.

Can insomnia return after treatment with CBT-I?

Reviews of several research studies of CBT-I’s long-term effectiveness suggest that the benefits continue to be present at 3- ,6-, and 12-months after treatment ends, in terms of participant scores on a validated measures of insomnia severity, length of time to fall sleep (sleep onset latency), and sleep efficiency (how much a person reports actually sleeping while in bed for the night). While effects may decline over time following treatment, clinically significant effects of CBT-I were shown to last up to a year after therapy was completed. Another recent National Institute of Health published study of CBT-I participants indicated, “Positive effects of CBT [for insomnia] were still present after ten years. Insomnia severity remained low, and two-thirds of participants no longer fulfilled criteria for an insomnia diagnosis. This extends previous findings of CBT, further confirming it as the treatment of choice for insomnia.” (https://pubmed.ncbi.nlm.nih.gov/35099359).

Anticipating the possibility of relapse, CBT-I patients are provided with instructions on methods to regain better sleep as treatment ends, and booster sessions can be requested to help recover or refine strategies and skills that may have faded over time. Good sleep is highly governed by good habits, and like any other habit, lapsing back into old patterns (e.g. staying up too late, taking naps, increasing caffeine consumption, increases in anxiety provoking thinking) can occur. When this happens, they key is to evaluate what has happened, learn from it, and re-introduce those behaviors, strategies, and skills that will lead to better sleep again.