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Trouble Sleeping (Insomnia)

What is Trouble sleeping?

Trouble sleeping—often called insomnia—refers to difficulty falling asleep, staying asleep, or getting restful sleep despite having the opportunity to do so. It is a common complaint that can be acute (lasting days to weeks) or chronic (lasting three months or longer). Poor sleep can impair cognition, mood, immune function, and overall quality of life.

According to the NIH, about one‑third of adults in the United States experience some form of insomnia each year, and ~10% develop chronic insomnia that requires treatment.<sup>1</sup>

Common Causes

Insomnia is rarely due to a single factor. Below are 10 frequent medical, psychological, and lifestyle contributors.

• Stress and anxiety – work pressures, financial worries, or traumatic events can activate the “fight‑or‑flight” response, making it hard to relax.
• Depressive disorders – depression may cause early‑morning awakening or excessive sleepiness during the day.
• Medical conditions – chronic pain (arthritis, fibromyalgia), GERD, asthma, hyperthyroidism, Parkinson’s disease, and Parkinson’s disease can disrupt sleep.
• Medications – stimulants (e.g., methylphenidate), corticosteroids, certain antidepressants, beta‑blockers, and decongestants may interfere with sleep cycles.
• Caffeine, nicotine, and alcohol – caffeine and nicotine are stimulants; alcohol may help fall asleep but reduces REM sleep and causes early awakenings.
• Shift work and irregular schedules – rotating or night shifts can misalign the body’s circadian rhythm.
• Sleep‑related breathing disorders – obstructive sleep apnea (OSA) leads to frequent arousals.
• Restless legs syndrome (RLS) and periodic limb movement disorder – uncomfortable sensations provoke leg movements that interrupt sleep.
• Environmental factors – excessive light, noise, an uncomfortable mattress, or a temperature that’s too hot or cold.
• Neurological disorders – Alzheimer’s disease, Parkinson’s disease, and traumatic brain injury can alter sleep architecture.

Associated Symptoms

When insomnia is present, patients often report a cluster of related complaints:

• Daytime fatigue or excessive sleepiness
• Difficulty concentrating, memory lapses, or “brain fog”
• Irritability, mood swings, or heightened anxiety
• Headaches, especially upon waking
• Gastrointestinal disturbances (e.g., acid reflux) that may be both cause and effect
• Reduced libido or sexual dysfunction
• Weight changes – some people over‑eat to combat fatigue, while others lose appetite
• Decreased performance at work or school

When to See a Doctor

Most short‑term sleep problems improve with simple lifestyle changes, but medical evaluation is warranted when any of the following occur:

• Insomnia persists > 3 months despite self‑help measures.
• Difficulty sleeping ≥ 3 nights per week.
• Daytime functioning is markedly impaired (e.g., accidents, job performance decline).
• Symptoms of an underlying condition such as depression, anxiety, or chronic pain are present.
• You suspect a sleep‑related breathing disorder (snoring, gasping, witnessed apneas).
• Use of alcohol, caffeine, or medications to force sleep.
• Sudden onset of insomnia after a head injury, stroke, or new medication.

Diagnosis

Evaluation typically proceeds in a stepwise fashion.

1. Detailed History

• Sleep patterns (bedtime, wake time, naps, night awakenings).
• Lifestyle factors: caffeine/alcohol intake, exercise, screen use.
• Psychiatric history: stress, anxiety, depression.
• Medication and supplement review.
• Associated medical problems (pain, breathing issues, endocrine disorders).

2. Physical Examination

• Vital signs, BMI, and neck circumference (screening for OSA).
• ENT exam for nasal obstruction or tonsillar hypertrophy.
• Neurological assessment if movement disorders are suspected.

3. Screening Questionnaires

• Insomnia Severity Index (ISI)
• Epworth Sleepiness Scale (ESS) – evaluates daytime sleepiness.
• Pittsburgh Sleep Quality Index (PSQI)

4. Laboratory Tests (selected)

• Thyroid‑stimulating hormone (TSH) to rule out hyper/hypothyroidism.
• CBC, ferritin, and vitamin D if fatigue or RLS is suspected.

5. Objective Sleep Studies

• Polysomnography – overnight study performed in a sleep lab for suspected OSA, REM behavior disorder, or periodic limb movements.
• Home sleep apnea testing – less intensive for uncomplicated OSA suspicion.

Treatment Options

The goal is to improve both quantity and quality of sleep while addressing any underlying cause.

1. Cognitive‑Behavioral Therapy for Insomnia (CBT‑I)

Considered first‑line by the ACP and the AASM. CBT‑I combines sleep restriction, stimulus control, cognitive restructuring, and relaxation techniques over 6–8 weekly sessions. It has a success rate of 70‑80% and lasting benefits.<sup>2</sup>

2. Sleep Hygiene Education

• Maintain a consistent bedtime and wake‑time—even on weekends.
• Reserve the bedroom for sleep and intimacy only; avoid work, TV, or smartphones.
• Limit caffeine (< 400 mg) after 2 p.m.; avoid nicotine and large meals close to bedtime.
• Create a cool (60‑67 °F/15‑19 °C), dark, and quiet environment; consider blackout curtains or white‑noise machines.
• Engage in regular moderate‑intensity exercise, but finish vigorous activity at least 3 hours before bed.

3. Pharmacologic Options

Medication should be short‑term (≤ 4 weeks) unless a chronic plan is created with a sleep specialist.

• Prescription hypnotics – zolpidem, eszopiclone, or temazepam. Effective but carry risk of dependence, falls (especially in older adults), and next‑day sedation.
• Melatonin – 0.5‑5 mg taken 30 minutes before bedtime; useful for circadian‑rhythm disorders (e.g., jet lag, shift work).
• Low‑dose doxepin – approved for sleep maintenance insomnia, minimal anticholinergic side effects.
• Antidepressants (e.g., trazodone, mirtazapine) – sometimes used off‑label when insomnia co‑exists with depression.
• OTC sleep aids – diphenhydramine or doxylamine can cause anticholinergic side effects and are not recommended for routine use.

4. Treatment of Underlying Conditions

• CPAP or Bi‑PAP for obstructive sleep apnea.
• Iron supplementation for RLS with low ferritin.
• Optimizing pain control (physical therapy, NSAIDs, gabapentinoids).
• Adjusting or switching medications that disrupt sleep.
• Psychiatric therapies (counseling, antidepressants) for anxiety or depression.

5. Complementary Approaches

• Mindfulness‑based stress reduction (MBSR)
• Progressive muscle relaxation or guided imagery
• Aromatherapy (lavender essential oil) – modest benefit in some trials
• Acupuncture – limited evidence, may help in specific patient groups

Prevention Tips

Even if you have never had trouble sleeping, these habits can reduce future risk:

• Stick to a regular sleep‑wake schedule, even on vacations.
• Limit screen exposure (phones, tablets, TVs) at least 1 hour before bed; use night‑shift settings to reduce blue light.
• Maintain a balanced diet; avoid heavy, spicy, or sugary meals close to bedtime.
• Stay physically active – 150 minutes of moderate exercise per week is recommended by the CDC.
• Manage stress through journaling, yoga, or brief daily meditation.
• Screen for sleep problems during routine medical visits, especially if you have chronic illnesses.
• If you travel across time zones, gradually shift your sleep schedule 15‑30 minutes per day before departure.

Emergency Warning Signs

References

1. National Institutes of Health. Insomnia. Updated 2023.
2. American College of Physicians. Clinical Practice Guideline for the Treatment of Insomnia in Adults. ACP Guidelines, 2022.
3. Mayo Clinic. Insomnia. MayoClinic.org, accessed June 2026.
4. Centers for Disease Control and Prevention. Sleep and Sleep Disorders. CDC.gov, 2024.
5. World Health Organization. Global Burden of Disease – Sleep Disorders. WHO, 2023.

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