Insomnia: Symptoms, Causes, Diagnosis and Treatment

Not being able to get to – or stay – asleep, medically known as insomnia, can be more than a nuisance, in can be life-altering, and not in a good way. Unfortunately, it is also a very misunderstood and often overlooked condition that often goes untreated because those suffering from it don’t think that there is anything they can do about it, except live with it.

In this guide we are going to take a comprehensive look at insomnia; what is is, what causes it, how it can be medically diagnosed and what treatments and techniques may be able to help you get a better night’s sleep.

What is Insomnia?

Woman lying in bed looking at clock suffering from insomnia

In the simplest terms, insomnia is a difficulty in getting to, or remaining asleep. It may happen occasionally, or it may be a nightly struggle that goes on for days, weeks, months or even years.

Almost 40 million Americans suffer from chronic insomnia.

National Center for Biotechnology Information

It is more complicated than that though. Often, those who could be described as suffering from chronic insomnia get enough sleep in the end, with research showing that many only get around 30 minutes less sleep a night than those who consider themselves ‘good’ sleepers.

What is different however is the sleep experience. Many people who describe themselves as having – or are diagnosed with – insomnia – take a long time to initially fall asleep, wake often in the night, wake up feeling like they are not properly rested and/or are anxious and worried about the consequence of poor sleep.

Insomnia is very often used – even by medical professionals – as a catchall term for the experience of disturbed sleep. There are, however, clinical definitions of insomnia, and, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),  they can even been divided in separate diagnoses as follows:

  • Initial insomnia – a difficulty in falling asleep at a chosen bedtime
  • Middle insomnia – a difficulty remaining asleep
  • Terminal insomnia – waking earlier than had been intended to get a ‘full night’s’ sleep

In addition, to obtain a clinical diagnosis of insomnia, patients must meet at least some of the following criteria:

  • Symptoms must occur at least three nights a week for a period of three months
  • The inability to get proper sleep occurs even though the person has adequate time to sleep
  • The lack of sleep causes a significant impairment to a person’s daily waking life
  • Cannot be better explained by a different condition ie: sleep apnea, depression, chronic pain or substance abuse.

Primary Versus Secondary Insomnia

With the criteria we just mentioned in mind, insomnia can be classified into primary and secondary insomnia.

Primary insomnia is considered to be present when it is unrelated to any other health condition, either mental or physical. It is also termed as idiopathic insomnia or nonorganic insomnia. This is the least common form of insomnia.

Secondary insomnia, as the name suggest, is the result of another condition. But even that can be divided into further subsections, according to the condition that seems to be causing the insomnia.

Paradoxial Insomnia

Yet another form of diagnosable insomnia is paradoxial insomnia. This is a formal term for the habit of mistaking sleep for being awake. Also referred to as pseudoinsomnia or sleep state misperception people suffering from this will believe that they have not slept for a significant amount of time but have actually slept for longer than they recall and have experienced better sleep quality than they believe as well.

As time is ‘distorted’ when we sleep – a dream, for example, is recalled as being very ‘long’ when in real time it lasted for just a few seconds – it can be easy to mistake a few moments of wakefulness as a much longer period of time.

Acute Vs. Chronic Insomnia

Insomnia can also be classified as either acute or chronic. Acute insomnia occurs occasionally or for a short period of time. If, for example, you recently lived through a traumatic sudden emotional or physical trauma you may have difficulty sleeping afterwards for a while but are then able to return to your normal sleep patterns once the ‘crisis’ has passed.

Chronic insomnia, on the other hand, means that, whatever its cause, or whether or not it is primary or secondary, the insomnia persists for a period of three months or longer. In many cases people suffer from insomnia for years.

Insomnia Vs. Other Sleep Disorders

What causes insomnia?

Many have heard of the term sleep medicine. Over the years medical professionals have realized that there are a wide range of sleep disorders that are unrelated to the idea of insomnia and sleep medicine has evolved as a formal medical discipline to research, diagnose and treat these conditions, rather than simply dismiss them as ‘common’ insomnia as had been the case in the past.

These conditions include:

  • Sleep Apnea
  • Restless Leg Syndrome
  • Narcolepsy
  • Circadian Rhythm Disorders
  • REM Sleep Behavior Disorder
  • Night Terrors
  • Sleep Paralysis

As insomnia can be easily mistaken for one of these conditions – which are completely different things – an increasing number of primary healthcare physicians are referring patients who believe they may be suffering from insomnia for more detailed clinical diagnosis by sleep medicine professionals.

Insomnia Causes

As evidenced by the issues we have covered here so far, insomnia is a complex and often badly diagnosed condition. This also means that it is much harder to define specific causes of a person’s insomnia. Again, it is this complexity that led to the rise of sleep medicine over the last five decades. However, there are some very common causes of basic insomnia that we can take a brief look at here.


Stress, although it’s usually seen as a bad thing, can be helpful. In its simplest form it is a chemical reaction in the body that occurs as a response to something that is difficult or challenging. So, if you are an athlete, or a person facing a difficult exam, a little stress can be a good thing.

About 23% of adults have trouble sleeping due to stress and anxiety.

Anxiety and Depression Association of America

Stress is never conducive to good sleep however. Stress causes a state of high arousal in the body, the opposite of the relaxed state that is needed for a person to sleep.

Poor Sleep Habits

There are all kinds of poor sleep habits that can contribute to insomnia. In fact, so many that it is very difficult to list of them all.

However, some common ones include:

  • Not maintaining a set sleep schedule
  • Eating or drinking too close to bedtime
  • Social jet leg (sleeping too much on weekends or days off)
  • Sleep effort – trying too hard to get to sleep
  • Lack of exercise
  • Attempting to sleep in poor ambient conditions (too light, too dark, too loud, with blue light screens active)

Medical Conditions

About 75% of people suffering from depression have insomnia.

National Center for Biotechnology Information

Secondary insomnia can be the result of a number of medical conditions, as we mentioned previously. This means that they must be addressed first. In the case of chronic medical conditions that persist and cannot be ‘cured’ insomnia can be addressed separately with varying degrees of success.

It should be noted that these underlying medical conditions are not just physical. Mental disorders can be just as troublesome when it comes to getting a good night’s sleep, and this is especially true of anxiety and depression.

Medications and Legal Drugs

Some prescription and over the counter medications can lead to acute insomnia. This can often be anticipated as most of the medications known to have this effect come with label warnings that state that fact.

What people consider less often is the effect of legal drugs on sleep. Nicotine and caffeine are both stimulants and are likely to make getting to sleep harder. Alcohol, although it often makes people sleepy (and can seem to ‘put them to sleep) often causes middle insomnia – difficulty staying asleep – as its effects wear off.


Women are twice as likely to develop insomnia.

Michigan Health

It’s been well documented statistically for many years that insomnia disparately affects women versus men. This is not completely understood, but recent research has begun to link an increased occurrence of insomnia in women to menstrual cycles and especially to menopause and perimenopause.


Older people seem to experience more insomnia than younger ones. Researchers believe this is not directly related to age but rather to the fact that people develop more chronic conditions – especially pain conditions – as they age that lead to disturbed or difficult sleeping.

Blue Light

Middle aged man sitting in front of laptop in bed at night time

Although research is still in its infancy, it does seem that exposure to blue light – the light emitted by your computer screen, your phone and some TVs – can affect your ability to get to sleep if the exposure occurs too close to bedtime.


Napping can be very good for you, but only when done correctly. When someone naps too close to their regular bedtime, or for too long (20-30 minutes is ideal) it is likely to impair their ability to sleep for the desired longer period of time at bedtime.

Room Temperature

While no believed to be a direct cause of insomnia trying to sleep in an environment that is too hot or too cold can make getting, or staying, asleep, difficult. Researchers are finding that the ideal temperature for a better night’s sleep seems to be between 65 and 70F.

Mattress Quality

Trying to sleep on an uncomfortable mattress is an almost obvious cause of what might seem to be unexplained insomnia and a simple change of mattress may solve the problem, and yet it is often something that people overlook when trying to work out why they are experiencing insomnia.

Light and Sound

Some people can sleep in very light or noisy conditions. That is not the case for most people though. Usually too much ambient light or sound makes falling asleep hard and they are easily woken from sleep by sudden loud noises.

Insomnia Symptoms

In addition to knowing that they have not slept enough, and a general feeling of tiredness, the following can also all be symptoms of insomnia:

Moodiness and/or Irritability: Those suffering from either acute or chronic insomnia often report feeling ‘on edge’ and display signs of unusual moodiness and/or intolerance of others.

Memory Difficulties: It’s not unusual for those who suffer from chronic insomnia to have trouble remembering things, and this is often coupled with an inability to concentrate for long periods of time.

Physical Clumsiness: People who have not got enough sleep tend, statistically – to be more prone to accidents such as tripping and falling or dropping things and to getting into car or work accidents.

[su_quote cite=”American Academy of Sleep Medicine” url=””]Insomniacs were 2.8 times more likely to die in a car crash because of tiredness than those who sleep well.[/su_quote]

Headaches: Some people who do not get enough sleep due to acute or chronic insomnia often report headaches of varying duration and severity, often on a daily basis and that are hard to relieve with over the counter medications.

Sleep Anxiety: Some people are so affected mentally by their insomnia that they develop a genuine anxiety of even trying to get to sleep, and may stay up longer than they should out of a sometimes unconscious avoidance of the now stressful act of trying to get sleep.

Diagnosing Insomnia

Man resting on pillow having problems sleeping

As previously mentioned, sleep medicine is now an established, formal branch of medicine. Thanks to this fact, insomnia in its many forms is now more easily diagnosed. This will usually involve not only physical examinations to rule out underlying conditions but a mental evaluation and often a sleep study.

A sleep study is conducted in a specialist lab and subjects are monitored as they sleep to look for patterns that may offer explanations for their apparent insomnia. This is one way that paradoxial insomnia is diagnosed, as patients who believe they are lacking sleep are found to have relatively normal sleep patterns after all.

Insomnia Treatments and Prevention

As you can now see, there are many forms, and many possible causes of insomnia. This means, logically, that there are also lots of ways it can be treated. There are also various things that can be implemented in order to try and prevent insomnia in the first place (or prevent it from reoccurring once it has been ‘treated’.) These range from formal medical interventions to alternative therapies and ‘home remedies’ to lifestyle and habit changes.

While it would be impossible to list them all here (as there really are so many) what follows is a look at some of the most commonly used modalities to treat insomnia.

Formal Prescription Medication Treatments

It has long been the practice to prescribe sleeping pills for patients suffering from various forms of insomnia. While it is still an accepted medical practice, and can be very helpful for those suffering for chronic insomnia with no underlying cause – primary insomnia as discussed earlier – the practice is now approached with far more caution, as these medications can have some serious side effects of their often, especially when it comes to developing a dependence upon them that makes it difficult for people to sleep at all without them.

Men and women taking sleeping pills may have a 3 times higher risk of early death.

BMJ Journals

There are still a number of over the counter sleep medications available. They can be effective for some people, and especially for the relief of acute insomnia, but again should be used with caution to avoid developing a dependence on them.

Cognitive Behavioral Therapy Insomnia Treatments

Cognitive behavioral therapy – or CBT as it is known for short – is actually used to treat all kinds of different disorders. The treatment comes in two parts – the cognitive part that means recognizing and identifying patterns and behaviors that may be causing the problem under investigation and then the behavioral part, which sees a patient actually begin to ‘change their ways” to try to correct the problem.

In the case of cognitive behavioral therapy insomnia treatments, the therapy usually lasts for several weeks if not months. CBT is not by any means a quick fix for insomnia – the way taking an OTC or prescription sleep aid can be – but it does more often get to the root of the patient’s insomnia, meaning that the chances that they can combat it for good are far higher.

Herbal Remedies for Insomnia

A hot cup of herbal chamomile tea

Herbs have been used by people from all over the world to treat all kinds of ailments and health conditions for centuries and in fact many modern prescription medications are themselves derived from herbs.

When it comes to treating insomnia there are a number of herbal remedies for insomnia that many people find are very effective, bringing them relief from sleepless nights without the side effects that prescription medications might have.

There are a number of all-natural herbal supplements that are designed to help combat insomnia. Usually they contain at least one of the following:

  • Chamomile – Chamomile is a daisy like flower that has been used as an aid for insomnia and as a general relaxant for centuries. In addition to taking it in supplement form it can also be taken as a tea which is very pleasant if you add a little honey to it. 
  • Valerian Root – Valerian root is another well used herbal remedy for insomnia and some clinical testing has even been performed to try to discover just how it might work to induce sleep. Many of those studies seem to indicate that there is a substance in the valerian that seems to affect the brain’s GABA receptor pathway to induce sleep in the same way that a prescription sleep aid does, meaning in essence that may be as effective as those but without any of the potential chemical side effects.
  • Passionflower – Passionflower extract is such a powerful sleep aid that it is used as one of the major ingredients in many of the over the counter sleep aids that are sold in Europe. Passionflower is actually a very useful little herb as it can also be used to help relieve asthma symptoms and reduce nervousness.
  • St John’s Wort – St John’s Wort is often linked to relieving the symptoms of mild depression but it can be a very effective sleep aid as well.

Lifestyle Changes

For some, simple lifestyle changes are all that is needed to help them combat both acute and chronic primary insomnia. Here are some common ones that are often effective:

Developing a Formal Bedtime Routine

Couple sleeping in bed with alarm clock how much sleep

Often insomnia can be attributed to the things we do in the hours leading up to bedtime, and so developing a formal bedtime routine that makes use of good pre sleep habits can be very effective.

This might include ensuring that you avoid exercise and eating a heavy meal at least three to four hours before sleep, turning off all blue light emitting devices at least thirty minutes before bed and making a concerted effort to relax. Meditation, listening to soothing music or taking a warm bath can all be good ways to do this.

Ensuring an Optimal Sleep Environment

A decluttered bedroom is sleep inducing

The more conducive your bedroom is to sleep the better. This should begin with the bed itself. Although a new mattress can seem like a significant investment to make it is often a very good one. The ‘right’ mattress should be both supportive and comfortable and should not ‘sleep hot’, something that can be the case for memory foam mattresses.

There should also be as little noise and light as possible. If your bedroom lets in too much light – from streetlights perhaps – or you need to sleep during daytime hours (common for shift workers) a small investment in room darkening curtains can be a very good one. If you cannot control outside noise levels (traffic, a snoring partner etc.) earplugs may be helpful. Modern earplugs are inexpensive and have noise cancelling and noise reduction properties but will still allow you to hear your alarm clock when the time is right.

In Conclusion

Insomnia is a complex condition – often far more complex than simply ‘not being able to get to sleep.’ It is not one that should be ignored however, and while home remedies, over the counter treatments and lifestyle changes, like the ones we have covered here, can be effective, chronic insomnia should always be discussed with a medical professional, both to rule out other and underlying conditions and to create a treatment plan more likely to work for you.