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Insomnia

Insomnia is a prevalent sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or experiencing nonrestorative sleep, despite having adequate opportunity and environmental conditions for sleep, often resulting in daytime impairments such as fatigue, impaired concentration, or mood disturbances.^[1]^[2]^[3] It manifests in two primary forms: acute insomnia, which is short-term and typically lasts from a few days to several weeks, often triggered by temporary stressors like life events or travel; and chronic insomnia, defined as occurring at least three nights per week for three months or longer, which may persist independently or alongside other health conditions.^[2]^[4] Prevalence estimates indicate that approximately 30% of adults report insomnia symptoms, with about 10% experiencing significant daytime consequences, and rates are higher among women, older adults, and those with comorbid medical or psychiatric disorders.^[3]^[1] Common nighttime symptoms include prolonged time to fall asleep, frequent awakenings, or early morning awakenings with inability to return to sleep, while daytime effects encompass excessive sleepiness, irritability, reduced performance at work or school, and increased risk of errors or accidents.^[1]^[4] These disruptions can exacerbate underlying issues, contributing to heightened risks for conditions such as hypertension, diabetes, and depression.^[2] Etiologically, insomnia arises from a combination of factors, including psychological stressors like anxiety or grief, physiological hyperarousal involving elevated cortisol levels, poor sleep hygiene practices such as irregular schedules or caffeine consumption, and comorbidities including mental health disorders (e.g., depression affecting up to 40% of cases), chronic pain, or other sleep disorders like sleep apnea.^[3]^[1]^[4] Treatment approaches emphasize non-pharmacological interventions as first-line options, such as cognitive behavioral therapy for insomnia (CBT-I), which addresses maladaptive thoughts and behaviors to improve sleep patterns, alongside sleep hygiene education; medications like hypnotics may be used short-term for severe cases, but underlying causes must also be managed to prevent recurrence.^[4]^[2]^[1]

Signs and Symptoms

Sleep Disturbances

Insomnia is fundamentally characterized by disruptions in the nighttime sleep process that persist despite sufficient opportunity for rest. The primary sleep disturbances include difficulty initiating sleep, often quantified as a sleep onset latency exceeding 30 minutes, where individuals struggle to fall asleep after retiring to bed.^[5] This prolonged latency reflects an inability to transition effectively into sleep, distinguishing it from brief delays that may occur occasionally in healthy individuals.^[6] Maintenance of sleep is another core issue, involving frequent awakenings during the night or prolonged periods of wakefulness after sleep onset, typically greater than 30 minutes.^[7] Early morning awakenings, where individuals wake earlier than desired and cannot return to sleep, further exacerbate this fragmentation, often resulting in total sleep time below 6.5 hours.^[7] These interruptions lead to fragmented sleep architecture, with reduced sleep efficiency—defined as the percentage of time in bed spent asleep—falling below 85%.^[7] Non-restorative sleep, characterized by a subjective sense of unrefreshing rest despite adequate duration, accompanies these problems but does not occur in isolation; it must coexist with initiation or maintenance difficulties to meet diagnostic thresholds.^[5] These disturbances differ from normal sleep variability, which involves occasional nights of suboptimal sleep due to transient factors like stress or environmental changes, without the persistence or associated distress required for a disorder diagnosis. In insomnia, the issues must occur at least three nights per week for a minimum of three months to signify a chronic pattern, rather than episodic fluctuations typical in the general population.^[5] This chronicity underscores the disorder's impact on overall sleep continuity, as measured by polysomnography or sleep diaries in clinical settings.^[7]

Daytime Impairments

Insomnia leads to a range of daytime impairments that significantly affect cognitive, emotional, physical, and functional domains of daily life. These consequences arise from disrupted sleep continuity and quality, as detailed in prior discussions of sleep disturbances, and contribute to reduced overall well-being. Research consistently shows that individuals with insomnia experience heightened vulnerability to these effects, which can persist even after apparent sleep recovery.^[8] Cognitive deficits are prominent among daytime impairments in insomnia, particularly affecting attention, memory, and decision-making. Studies indicate that people with insomnia exhibit reduced sustained attention and increased attentional lapses, leading to difficulties in maintaining focus on tasks.^[9] Memory impairments, including deficits in working memory and episodic recall, have been observed through objective neuropsychological testing, with insomnia sufferers showing poorer performance compared to good sleepers.^[10] Decision-making processes are also compromised, as evidenced by heightened risk-taking and slower problem-solving in simulated scenarios, underscoring the impact on executive function.^[11] Emotional disturbances manifest as irritability, anxiety, and depressed mood, exacerbating the psychological burden of insomnia. Individuals often report elevated irritability and emotional reactivity during waking hours, which correlates with poorer sleep efficiency.^[12] Anxiety symptoms, including heightened worry and physiological arousal, are prevalent and linked to daytime dysfunction, with insomnia significantly increasing the risk of clinical anxiety.^[13] Depressed mood is similarly common, with chronic insomnia associated with symptoms such as low energy and persistent sadness, independent of primary mood disorders.^[14] Physical symptoms during the day include fatigue, headaches, and gastrointestinal issues, reflecting the systemic toll of sleep disruption. Fatigue is a core complaint, characterized by persistent tiredness and reduced physical endurance, reported by the majority of insomnia patients.^[15] Headaches, often tension-type, occur frequently and may stem from heightened muscle tension or altered pain sensitivity.^[5] Gastrointestinal disturbances, such as abdominal discomfort or altered bowel habits, are linked to sleep deprivation's effects on gut motility and inflammation.^[16] Functional impacts extend to work performance, driving safety, and social relationships, impairing overall productivity and interpersonal dynamics. At work, insomnia reduces performance through errors, absenteeism, and lower output, with affected individuals engaging in fewer safety behaviors.^[17] Driving safety is compromised, as insomnia elevates crash risk via impaired vigilance and reaction times during monotonous tasks.^[18] Socially, it strains relationships by fostering conflicts and reducing empathy, leading to isolation and diminished quality of life.^[19] The Insomnia Severity Index (ISI) is a validated tool for assessing daytime complaints, with items specifically targeting functional impairments like satisfaction with sleep and daytime interference. Scores on these items help quantify the severity of cognitive, emotional, and physical effects, guiding clinical evaluation.^[20]

Behavioral Indicators

Individuals with insomnia often exhibit maladaptive behaviors that perpetuate sleep difficulties by interfering with natural sleep processes. One prominent indicator is excessive time spent in bed without achieving sleep, known as bedtime prolongation, where individuals extend their time in bed in an attempt to compensate for lost sleep, but this reduces sleep drive and efficiency, leading to prolonged wakefulness after sleep onset.^[21] According to the 3P model of insomnia, such behaviors maintain the disorder by disrupting homeostatic sleep regulation.^[22] Irregular sleep schedules and excessive napping further exacerbate insomnia by desynchronizing the circadian rhythm and diminishing the pressure to sleep at night. People may shift bedtimes erratically or nap during the day to alleviate daytime fatigue, which fragments nighttime sleep and reinforces the cycle of poor sleep quality.^[21] These patterns are common perpetuating factors identified in behavioral models of insomnia.^[22] Worry about sleep can lead to conditioned arousal, where anxiety over not sleeping becomes associated with the bedroom environment, triggering physiological hyperarousal upon entering bed. This conditioned response, characterized by increased heart rate and cognitive rumination, hinders sleep initiation and is a core feature of psychophysiological insomnia.^[23] Research shows that such worry strengthens sleep-interfering associations over time. Avoidance of sleep-related activities due to fear of failure manifests as safety behaviors, such as delaying bedtime or leaving the bed if sleep does not come quickly, aimed at preventing the distress of perceived sleep failure. These strategies, while temporarily reducing anxiety, maintain insomnia by weakening the bed-sleep association and promoting irregular habits.^[24] Studies indicate that such avoidance behaviors correlate with greater insomnia severity.^[25] The use of digital media before bedtime plays a significant role in delaying sleep onset, as exposure to blue light from screens suppresses melatonin production and heightens cognitive arousal. Evening screen time, particularly for more than one hour, has been linked to a 59% increased risk of insomnia symptoms and reduced sleep duration by approximately 24 minutes per night.^[26]

Causes and Risk Factors

Predisposing Factors

Predisposing factors for insomnia encompass inherent vulnerabilities that heighten an individual's susceptibility to the disorder, including genetic, demographic, and physiological elements. Genetic influences play a significant role, with twin studies estimating the heritability of insomnia at 30-50%, indicating that genetic factors account for a substantial portion of the variance in insomnia risk.^[27] Family history further supports this, as individuals with a first-degree relative affected by insomnia exhibit elevated risk, corroborated by twin and adoption studies demonstrating shared genetic liabilities beyond environmental influences.^[28] Specific genes, such as PER2, a core component of the circadian clock, have been implicated through polymorphisms associated with disrupted sleep regulation and increased insomnia vulnerability.^[29] Age-related changes represent another key predisposing factor, with insomnia prevalence peaking in older adults due to alterations in circadian rhythms, including phase advances that lead to earlier sleep onset and awakenings.^[1] These shifts, often compounded by reduced melatonin production and fragmented sleep architecture, make elderly individuals more prone to chronic sleep difficulties.^[30] Female sex confers a higher risk for insomnia, primarily attributed to hormonal fluctuations across the lifespan, such as those during menstrual cycles, pregnancy, and particularly menopause, where estrogen decline disrupts sleep continuity in up to 40-60% of women.^[31] Chronic medical conditions also predispose individuals, with disorders like persistent pain syndromes (e.g., fibromyalgia or arthritis) and respiratory issues (e.g., chronic obstructive pulmonary disease or asthma) interfering with sleep initiation and maintenance through discomfort and breathing difficulties.^[32] These comorbidities create a baseline vulnerability that amplifies insomnia development when combined with other stressors.^[33]

Precipitating Factors

Precipitating factors are acute events or conditions that initiate episodes of insomnia by disrupting normal sleep patterns, often leading to short-term sleep difficulties that may resolve or evolve further. These triggers can vary widely but commonly involve sudden changes in an individual's circumstances or physiology.^[34] Life stressors, such as job loss, bereavement, or trauma, frequently act as primary precipitants by heightening arousal and emotional distress, thereby interfering with sleep initiation and maintenance. For instance, work-related events like job loss and family issues including bereavement were identified as the most common triggers in a study of insomnia patients, with 65% of such events carrying a negative emotional valence. Trauma exposure, particularly in contexts like posttraumatic stress, has been shown to directly contribute to the onset of insomnia through hyperarousal mechanisms following the event.^[35]^[36] Substance-induced triggers encompass the acute effects of caffeine, alcohol, nicotine, and certain medications, which can alter sleep architecture and promote wakefulness. Caffeine blocks adenosine receptors, delaying sleep onset when consumed later in the day, while alcohol initially sedates but fragments sleep in the second half of the night. Nicotine, as a stimulant, increases sleep latency and reduces total sleep time, and medications like stimulants or beta-blockers can exacerbate insomnia by interfering with circadian rhythms or causing side effects such as nightmares or restlessness.^[32]^[37] Environmental disruptions, including excessive noise, light exposure, or irregular work schedules like shift work, precipitate insomnia by desynchronizing the body's internal clock or creating an unsuitable sleep setting. Shift work, for example, forces sleep during daylight hours, leading to reduced sleep efficiency due to circadian misalignment. Similarly, sudden changes in ambient conditions, such as unfamiliar noise or light in a new environment, can acutely hinder sleep consolidation. Recent research highlights the role of digital devices and screen time as modern precipitants, with evening exposure to blue light suppressing melatonin and social media use increasing anxiety, contributing to sleep onset difficulties as of 2024.^[38]^[39] Acute illnesses or pain episodes often trigger insomnia by causing discomfort or physiological arousal that overrides sleep drives. Conditions involving pain, such as acute injuries or infections, disrupt sleep through heightened sensory input and inflammation, with studies noting their role in initiating sleep disturbances alongside other health burdens like dyspnea.^[40] Jet lag and travel-related circadian misalignment precipitate insomnia by rapidly shifting the sleep-wake cycle across time zones, resulting in difficulty falling asleep at the destination's nighttime. This misalignment typically causes transient insomnia lasting days to weeks, depending on the number of zones crossed and direction of travel.^[41]

Perpetuating Factors

Perpetuating factors in insomnia refer to the ongoing psychological, behavioral, and physiological elements that sustain sleep difficulties long after initial precipitating events have subsided, transforming transient sleep problems into a chronic disorder. Central to understanding these factors is the 3P model proposed by Spielman and colleagues, which delineates predisposing traits, precipitating triggers, and perpetuating mechanisms; specifically, perpetuating factors encompass maladaptive responses and habits that reinforce hyperarousal and disrupt sleep continuity, preventing natural recovery. This model highlights how these elements create a self-sustaining cycle, where attempts to compensate for poor sleep inadvertently exacerbate the problem.^[42] Maladaptive coping strategies, such as excessive worry about sleep loss or engaging in safety behaviors like clock-watching and repeated attempts to fall asleep, play a key role in maintaining insomnia by heightening cognitive arousal and prolonging wakefulness in bed. These behaviors often arise as individuals try to control their sleep but instead amplify anxiety and frustration, leading to a vicious cycle of rumination that interferes with sleep onset and quality. For instance, safety behaviors like lying awake while monitoring the time can extend time in bed without improving sleep efficiency, further entrenching the disorder.^[43]^[44] Conditioned arousal represents another critical perpetuating factor, where the bed and bedroom environment become associated with wakefulness and distress rather than rest, due to repeated experiences of struggling to sleep. This classical conditioning process results in physiological and cognitive activation upon entering the sleep setting, even in the absence of immediate stressors, as the cues trigger hyperarousal that inhibits sleep initiation. Over time, this association strengthens, making the bedroom a source of anxiety and perpetuating the insomnia independently of original causes.^[45]^[46] Poor sleep hygiene practices, including irregular sleep-wake schedules, excessive napping, or stimulating activities before bed, reinforce the insomnia cycle by disrupting circadian rhythms and consolidating wakefulness during intended sleep periods. These habits, often adopted in response to initial sleep difficulties, lead to fragmented sleep architecture and reduced sleep drive, as prolonged time in bed dilutes the homeostatic pressure for sleep without addressing underlying arousal. Evidence indicates that such practices are particularly insidious in chronic cases, where they prevent the re-establishment of efficient sleep patterns.^[47] Comorbid mental health conditions, particularly anxiety disorders, sustain insomnia by maintaining a state of chronic hyperarousal that heightens physiological and emotional activation, making relaxation and sleep attainment more challenging. In individuals with co-occurring anxiety, symptoms like persistent worry and autonomic overactivity perpetuate sleep disturbances through shared neurobiological pathways, such as elevated hypothalamic-pituitary-adrenal axis activity, which delays sleep onset and increases awakenings. This interplay underscores how untreated anxiety can transform episodic insomnia into a persistent condition, with studies showing bidirectional reinforcement between the two.^[48]^[49]

Pathophysiology

Neurobiological Mechanisms

Insomnia is fundamentally characterized by a state of hyperarousal, encompassing heightened physiological, cognitive, and cortical activation that disrupts sleep initiation and maintenance. This theory posits that individuals with insomnia exhibit persistent overactivity across multiple levels, from molecular processes to whole-brain networks, preventing the necessary deactivation of arousal systems during sleep attempts.^[23] Key physiological markers include elevated evening and nocturnal cortisol levels, reflecting dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which sustains stress responses incompatible with sleep.^[23] Sympathetic nervous system (SNS) activity is also enhanced, particularly during sleep onset, as evidenced by reduced cardiac pre-ejection period values indicating greater adrenergic drive.^[23] Furthermore, insomnia patients display an increased 24-hour metabolic rate, measured via higher oxygen consumption, suggesting a basal hypermetabolic state that undermines energy conservation needed for sleep.^[23] Neurotransmitter imbalances contribute significantly to this hyperarousal. Gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter, shows inconsistent but often reduced levels in key brain regions such as the occipital cortex and anterior cingulate, impairing inhibition of excitatory signals and promoting wakefulness.^[50] Serotonin dysregulation, particularly the short allele of the 5-HTTLPR gene, is associated with altered mood and arousal regulation, exacerbating sleep disturbances in susceptible individuals.^[23] Orexin (hypocretin), a wake-promoting neuropeptide from the lateral hypothalamus, exhibits elevated nocturnal activity in insomnia, stabilizing excessive wakefulness and disrupting the sleep-wake transition; this is targeted therapeutically by orexin receptor antagonists like suvorexant.^[51] Brain imaging studies reveal increased activity in hyperarousal networks, supporting the physiological evidence. Functional MRI findings indicate heightened functional connectivity between the locus coeruleus—a noradrenergic nucleus critical for arousal—and regions like the supramarginal gyrus and insula, correlating with subjective sleep quality impairments.^[52] Electroencephalography during sleep onset shows elevated beta activity in frontal regions, reflecting cortical hyperarousal, while structural MRI reveals reduced gray matter volume in prefrontal areas involved in executive control and emotion regulation.^[23] Circadian rhythm disruptions further perpetuate insomnia's neurobiological underpinnings. Melatonin secretion, which signals sleep readiness, is diminished in the evening and exhibits phase delays in patients with sleep-onset difficulties, misaligning the internal clock with desired sleep times.^[23] Core body temperature rhythms are similarly altered: sleep maintenance insomnia links to nocturnally elevated temperatures that inhibit sleep propensity, while onset and early awakening subtypes associate with delayed or advanced phase timings, respectively, disrupting the thermoregulatory drop essential for sleep.^[53] The sleep-wake regulation process, modeled as a "flip-flop switch," involves mutual inhibition between arousal-promoting neurons (e.g., in the locus coeruleus and orexin systems) and sleep-promoting neurons in the ventrolateral preoptic nucleus, ensuring stable state transitions via GABAergic and galanin-mediated suppression. In insomnia, this bistable mechanism is impaired, leading to chronic coactivation of wake and sleep circuits, state instability, and intrusions of wakefulness into sleep periods, as indicated by persistent brain hypermetabolism on positron emission tomography.^[54]

Cognitive and Behavioral Models

Cognitive and behavioral models of insomnia emphasize the role of psychological processes in maintaining sleep difficulties, integrating predisposing vulnerabilities with perpetuating thought patterns and learned habits. The Spielman 3P model, originally delineating predisposing, precipitating, and perpetuating factors, has been extended to incorporate cognitive elements, where predisposing traits such as negative affectivity heighten vulnerability to sleep-related worries, while perpetuating factors involve maladaptive cognitions and behaviors that sustain arousal. In this framework, cognitive aspects amplify the transition from acute to chronic insomnia by fostering heightened monitoring of sleep and unhelpful safety behaviors, such as excessive planning for bedtime routines.^[55] Central to these models are cognitive distortions, including catastrophic thinking about sleep loss, where individuals overestimate the consequences of poor sleep, such as impaired performance or health decline, thereby intensifying anxiety and delaying sleep onset. This pattern aligns with Allison Harvey's cognitive model of insomnia, which posits that such distortions contribute to a cycle of worry that perpetuates wakefulness.^[56] For instance, beliefs like "I must get eight hours of sleep or I will fail tomorrow" exemplify how these thoughts escalate pre-sleep arousal, distinguishing insomnia from other sleep issues by their specificity to sleep-related threats.^[56] Behavioral conditioning further entrenches insomnia through learned associations between the bed and alertness, often termed conditioned arousal, where repeated experiences of wakefulness in bed transform the sleep environment into a cue for vigilance rather than rest. This classical conditioning process, highlighted in stimulus control paradigms, leads individuals to avoid the bedroom during non-sleep times to re-associate it with sleep, breaking the cycle of hypervigilance.^[22] Such conditioning is a key perpetuating factor in the 3P model, as irregular sleep schedules reinforce the mismatch between sleep drive and environmental cues. Rumination on sleep failures and attentional bias toward sleep-related threats exacerbate these issues by directing focus to negative sleep cues, such as clock-watching or bodily sensations, which prolong cognitive arousal and inhibit sleep initiation. In Harvey's model, this bias maintains insomnia by amplifying threat perception, where neutral stimuli are interpreted as indicators of impending sleeplessness, supported by empirical evidence showing elevated rumination in insomnia patients compared to good sleepers.^[56] Studies indicate that this perseverative thinking extends daytime worries into the night, linking cognitive hyperarousal to prolonged sleep latency.^[57] Evidence from studies utilizing cognitive arousal scales underscores these mechanisms, with the Pre-Sleep Arousal Scale (PSAS) demonstrating higher cognitive subscale scores in individuals with insomnia, correlating with subjective sleep quality and daytime impairment. Validation research on the PSAS reveals that cognitive arousal items, such as racing thoughts about the day, predict insomnia severity more robustly than somatic factors, providing quantifiable support for targeted interventions. These findings affirm the interplay of cognitive and behavioral elements in sustaining insomnia, often intertwined with underlying physiological hyperarousal.^[58]

Diagnosis

Clinical Assessment

The clinical assessment of insomnia begins with a comprehensive evaluation to characterize the sleep complaint, its duration, severity, and impact on daytime functioning, ensuring adequate sleep opportunity is available despite the difficulties. This process typically involves gathering detailed patient history to identify patterns of sleep initiation, maintenance, or early awakening, along with associated nocturnal behaviors and daytime consequences such as fatigue or impaired concentration.^[59] Patient history taking is foundational and includes a thorough review of sleep-wake schedules, bedtime routines, environmental factors, and potential precipitating events like life stressors or travel. Clinicians often employ sleep diaries, where patients prospectively record sleep onset latency, awakenings, total sleep time, and daytime naps over 1-2 weeks to provide objective insights into sleep patterns and variability. Standardized questionnaires further quantify sleep quality and severity; for instance, the Pittsburgh Sleep Quality Index (PSQI) assesses multiple dimensions of sleep over the past month, with scores above 5 indicating poor sleep quality.^[59]80047-4) A physical examination is conducted to detect signs of comorbidities that may contribute to or mimic insomnia, such as obesity or enlarged neck circumference suggestive of obstructive sleep apnea, or features of thyroid dysfunction or chronic pain conditions. This exam also includes a mental status evaluation to gauge alertness, mood, and cognitive function.^[59] Differential diagnosis is essential to distinguish insomnia from other sleep disorders, including narcolepsy (characterized by excessive daytime sleepiness and cataplexy) or restless legs syndrome (with uncomfortable leg sensations prompting movement). It also rules out conditions like circadian rhythm disorders or insufficient sleep syndrome, often requiring consideration of overlapping symptoms through targeted questioning.^[59] Objective measures are used selectively when history alone is inconclusive. Actigraphy, involving wrist-worn devices to monitor rest-activity cycles, is indicated for assessing circadian patterns or compliance in patients with suspected rhythm disruptions or comorbidities like depression. Polysomnography (PSG), an overnight laboratory study recording brain waves, oxygen levels, and movements, is not routine but recommended if sleep-disordered breathing, periodic limb movement disorder, or treatment-refractory insomnia is suspected.^[59] Screening for substance use and mental health issues is integrated throughout the assessment, as caffeine, alcohol, nicotine, or illicit drugs can exacerbate sleep fragmentation, while conditions like anxiety or depression often co-occur with insomnia in up to 50% of cases. Validated tools such as the Epworth Sleepiness Scale or brief mental health screeners help identify these factors early.^[59]

Diagnostic Criteria and Types

Insomnia disorder is diagnosed based on standardized criteria outlined in major classification systems, primarily the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and the International Classification of Diseases, Eleventh Revision (ICD-11). These frameworks emphasize the presence of sleep dissatisfaction leading to clinically significant distress or impairment, with specific thresholds for frequency, duration, and exclusion of alternative explanations.^[60] In the DSM-5, the core diagnostic criteria for insomnia disorder require a predominant complaint of dissatisfaction with sleep quantity or quality, manifested as difficulty initiating sleep, maintaining sleep (characterized by frequent awakenings or prolonged time to return to sleep), early-morning awakening with inability to return to sleep, or nonrestorative sleep. This sleep disturbance must cause clinically significant distress or impairment in social, occupational, educational, or other key areas of functioning; occur at least three nights per week; persist for at least three months; and arise despite adequate opportunity for sleep. Additionally, the insomnia cannot be better explained by another sleep-wake disorder (such as narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or parasomnia), nor attributable to the physiological effects of a substance (e.g., drug abuse or medication). Coexisting mental disorders or medical conditions do not preclude the diagnosis if the insomnia complaint warrants independent clinical attention, though specifiers are used to note comorbidities like non-sleep disorder mental conditions, other medical issues, or other sleep disorders. The ICD-11, implemented post-2019, aligns closely with DSM-5 but introduces refinements for chronicity and nosology within its sleep-wake disorders chapter (6D). Insomnia disorders are defined by persistent difficulty with sleep initiation, duration, consolidation, or quality, occurring at least three times per week for at least three months (chronic insomnia, code 6D51), causing significant distress or impairment in personal, family, social, educational, occupational, or other functioning, and persisting despite adequate opportunity and circumstances for sleep.^[61] Short-term insomnia (code 6D50) follows similar features but lasts less than three months.^[62] As in DSM-5, the condition must not be better explained by another sleep-wake disorder, mental disorder, medical condition, substance use, or environmental factors.^[61] ICD-11 emphasizes a unified approach to insomnia regardless of comorbidities, without requiring causal attribution to other conditions. Insomnia is classified into types based on duration and presentation. Acute insomnia, also termed short-term or adjustment insomnia, involves symptoms lasting less than three months, often triggered by identifiable stressors, and resolves spontaneously or with intervention.^[62] Chronic insomnia persists for three months or longer, representing the more severe, enduring form that requires targeted diagnosis and management.^[61] Subtypes are delineated by the primary sleep complaint: onset insomnia (difficulty falling asleep), maintenance insomnia (trouble staying asleep due to awakenings), early morning awakening (waking too early with inability to resume sleep), or mixed/nonrestorative types combining these features. Distinctions between primary and comorbid insomnia have evolved in modern criteria. Earlier systems like DSM-IV separated primary insomnia (independent of other conditions) from secondary forms linked to psychiatric, medical, or substance-related issues; however, DSM-5 and ICD-11 eliminate this dichotomy, diagnosing insomnia disorder as a standalone entity even when comorbid, provided it meets full criteria and merits separate attention.^[61] This shift recognizes insomnia's bidirectional relationships with comorbidities without implying causality. Exclusion criteria across both systems rule out hypersomnolence disorders (e.g., excessive daytime sleepiness without insomnia features) or parasomnias (e.g., abnormal behaviors during sleep like sleepwalking), ensuring the diagnosis captures true insomnia phenomenology.^[61]

Prevention

Lifestyle Modifications

Maintaining a consistent sleep-wake schedule is a foundational lifestyle modification for preventing insomnia, as it helps regulate the body's circadian rhythm and promotes stable sleep patterns. Individuals are advised to go to bed and wake up at the same time every day, including weekends, to avoid disruptions from irregular shifts that can desynchronize internal clocks and increase insomnia risk.^[63]^[64] Optimizing the sleep environment plays a crucial role in fostering conditions conducive to restful sleep and reducing the likelihood of insomnia onset. Bedrooms should be kept cool (ideally 16–20°C or 60–68°F), dark (using blackout curtains or eye masks to block light), and quiet (employing earplugs or white noise machines to minimize disturbances), as these factors directly influence sleep initiation and maintenance by minimizing sensory interruptions.^[65]^[66]^[67] Dietary adjustments can significantly mitigate insomnia risk by avoiding stimulants and digestive discomfort near bedtime. Limiting caffeine intake after noon is recommended, as its half-life can extend up to 8 hours, potentially delaying sleep onset and reducing sleep quality; similarly, heavy or spicy meals should be avoided close to bedtime to prevent indigestion and reflux that disrupt sleep.^[68]^[64]^[69] Incorporating regular physical activity into daily routines supports insomnia prevention by enhancing overall sleep quality, though timing is essential to avoid interference with bedtime. Moderate exercise, such as walking or aerobic activity for at least 30 minutes most days, promotes deeper sleep stages, but vigorous sessions should be scheduled at least 4 hours before bed to allow body temperature and arousal levels to normalize.^[70]^[71]^[72] Routine use of relaxation techniques, such as progressive muscle relaxation (PMR), can prevent insomnia by reducing pre-sleep tension and promoting a calm state conducive to sleep. PMR involves systematically tensing and releasing muscle groups from toes to head, which has been shown to decrease anxiety and improve sleep efficiency when practiced nightly before bed.^[73]^[74]^[75]

Early Intervention Strategies

Early intervention strategies target high-risk individuals exposed to precipitating events or vulnerabilities, aiming to disrupt the progression from acute sleep disturbances to chronic insomnia through proactive, tailored approaches. These strategies emphasize timely identification and modifiable behaviors to preserve sleep architecture and prevent perpetuation.^[76] Stress management programs are essential for individuals facing precipitating events, such as shift work, which disrupts circadian rhythms and heightens insomnia risk. Mindfulness-based stress reduction (MBSR) has shown efficacy in reducing sleep-related worry and improving sleep quality among shift workers by enhancing emotional regulation and decreasing cognitive arousal. For instance, trait mindfulness correlates inversely with sleep disturbances in shift nurses, suggesting protective effects against insomnia onset. These programs typically involve 8-week structured sessions focusing on meditation and body awareness to mitigate fatigue and unwanted nocturnal wakefulness.^[77]^[78]^[79] Screening and education initiatives are critical for vulnerable populations, including the elderly and postpartum women, where predisposing factors like age-related circadian shifts or hormonal changes amplify insomnia susceptibility. In older adults, routine use of validated tools such as the Insomnia Severity Index (ISI) during annual assessments facilitates early detection, with education on sleep hygiene and cognitive behavioral principles promoting non-pharmacological management to avert chronicity. For postpartum women, behavioral-educational interventions delivered prenatally and postnatally, including sleep diaries and relaxation techniques, enhance maternal sleep duration and perceptions, reducing the trajectory toward persistent insomnia. These efforts often integrate into primary care or maternity programs, emphasizing consistent routines and light exposure to align circadian rhythms.^[80]^[81]^[82] Brief behavioral interventions following trauma offer a targeted approach to prevent insomnia chronicity by addressing immediate sleep disruptions like nightmares and hyperarousal. Brief Behavioral Therapy for Insomnia (BBTI), a 4-session protocol incorporating stimulus control and sleep restriction, significantly improves sleep efficiency and reduces trauma-related nightmares in the acute phase, potentially halting progression to long-term disorders. Imagery Rehearsal Therapy (IRT), often delivered in 1-3 sessions, rewires nightmare content to diminish frequency and intensity, supporting overall sleep consolidation post-trauma. Early implementation within 30 days of exposure maximizes prevention of PTSD-linked insomnia.^[83]^[84]^[85] Workplace policies promoting circadian health are vital for rotating shift workers, who face elevated insomnia risks due to irregular schedules. Evidence-based policies include optimized shift rotations with 4-5 recovery days between day and night shifts, combined with controlled bright light exposure during shifts and dim lighting post-shift to realign endogenous rhythms. Educational components, such as pre-shift napping guidelines and fatigue monitoring, further mitigate sleep debt, with meta-analyses confirming moderate reductions in insomnia symptoms through these organizational adjustments. Implementing such policies via employer training enhances compliance and sustains workforce sleep health.^[86]^[87] Community-based programs addressing digital media risks in youth focus on curbing screen-induced delays in sleep onset, a common precipitant in adolescents. The Sleep Ninja app, a free CBT-I-based smartphone intervention co-developed with youth input, gamifies sleep hygiene education and includes features to limit bedtime device use, such as automated notifications and relaxation modules, leading to improved sleep duration and reduced disturbances in community trials. School-integrated initiatives promoting media-free zones before bed and peer-led workshops further reinforce these habits, targeting the high prevalence of evening screen exposure among youth, with nearly 99% of adolescents using screens in the two hours before bed, contributing to sleep disturbances.^[88]^[89]^[90]

Treatment

Non-Pharmacological Approaches

Cognitive Behavioral Therapy for Insomnia (CBT-I) represents the cornerstone of non-pharmacological treatment for insomnia, endorsed as the first-line intervention by major sleep medicine organizations due to its robust evidence base and long-term benefits. Developed through foundational research in the 1990s and refined in subsequent decades, CBT-I typically involves 6 to 8 sessions and targets the cognitive, behavioral, and physiological factors perpetuating sleep difficulties. Key components include stimulus control, which strengthens the association between the bed and sleep by instructing patients to leave the bedroom if unable to sleep after 20 minutes and to avoid non-sleep activities in bed; sleep restriction, which limits time in bed to match actual sleep time, gradually increasing it as sleep efficiency improves to consolidate sleep; and cognitive restructuring, which identifies and challenges maladaptive beliefs about sleep, such as catastrophic thinking about sleepless nights, to reduce anxiety and arousal. These elements work synergistically to break the cycle of insomnia, with sleep hygiene education often integrated as an adjunct to promote consistent routines. Clinical trials and meta-analyses demonstrate that CBT-I achieves improvement rates of 70-80% in reducing insomnia severity, with many patients experiencing sustained effects for up to 12 months or longer post-treatment, outperforming waitlist controls and showing comparable or superior durability to pharmacological options. For instance, response rates, defined as clinically significant reductions in insomnia symptoms, reach 70-80%, while remission rates hover around 40%, highlighting its potential for lasting resolution without reliance on ongoing intervention. These outcomes are supported by improvements in sleep efficiency, reduced sleep onset latency, and enhanced daytime functioning, as evidenced across diverse populations including adults with chronic insomnia. Acceptance and Commitment Therapy (ACT), adapted for insomnia (ACT-I), offers an alternative psychological approach by emphasizing mindfulness, acceptance of sleep-related thoughts and sensations, and commitment to value-driven behaviors rather than direct control over sleep. ACT-I protocols typically include 6-8 sessions focusing on defusion from unhelpful sleep cognitions, present-moment awareness during bedtime routines, and aligning daily activities with personal values to mitigate insomnia's interference with life quality. Emerging evidence from randomized controlled trials indicates ACT-I yields moderate to large effects on insomnia severity and sleep quality, comparable to CBT-I in some contexts, particularly for patients with high emotional avoidance or comorbid anxiety, with benefits persisting at 6-month follow-up. To enhance accessibility, internet-based and app-delivered CBT-I (iCBT-I or dCBT-I) have proliferated since 2020, delivering core components through guided modules, interactive tracking, and automated feedback via platforms accessible on smartphones or computers. Recent randomized trials from 2020-2025 show dCBT-I produces similar efficacy to in-person CBT-I, with 60-75% of users achieving clinically meaningful improvements in sleep parameters and adherence rates exceeding 70% due to its self-paced, low-cost nature, making it suitable for underserved populations in remote or low-resource settings. These digital formats often incorporate multimedia elements like audio relaxations and progress dashboards, broadening reach without compromising therapeutic integrity. CBT-I can also be effectively delivered in group formats, typically involving 6-8 weekly sessions of 90 minutes each for 6-12 participants, fostering peer support while covering the same core components through structured discussions and homework review. Group therapy maintains high efficacy, with meta-analyses reporting insomnia severity reductions equivalent to individual delivery, and it optimizes resource use in clinical settings. Therapists delivering CBT-I, whether individual or group, require specialized training, often at the master's level in psychology, nursing, or related fields, including 20-40 hours of didactic instruction, supervised practice, and fidelity monitoring to ensure adherence to evidence-based protocols, as outlined in certification programs from organizations like the Society of Behavioral Sleep Medicine.

Pharmacological Treatments

Pharmacological treatments for insomnia primarily target neurotransmitter systems involved in sleep regulation, offering symptomatic relief for sleep onset and maintenance difficulties. These medications are typically recommended for short-term use in adults with chronic insomnia, following guidelines from authoritative bodies like the American Academy of Sleep Medicine (AASM), due to potential risks including dependence, tolerance, and next-day impairment. Selection depends on patient-specific factors such as age, comorbidities, and insomnia subtype, with ongoing monitoring essential to balance efficacy and safety.^[91] Benzodiazepines, exemplified by temazepam, act by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) at GABA_A receptors in the central nervous system, thereby facilitating sedation and reducing sleep latency.^[92] Temazepam is particularly useful for sleep maintenance insomnia, with clinical trials demonstrating improvements in total sleep time and wake after sleep onset compared to placebo.^[93] However, their use is limited to short-term (typically 2-4 weeks) due to risks of physical dependence, withdrawal symptoms upon discontinuation, and increased potential for falls and cognitive impairment, especially in older adults.^[94] Long-term use has been associated with higher relapse rates and tolerance development in European cohort studies.^[95] Non-benzodiazepine hypnotics, known as Z-drugs like zolpidem, selectively bind to the alpha-1 subunit of GABA_A receptors, mimicking benzodiazepine effects but with a more targeted action to minimize daytime sedation.^[96] Zolpidem effectively reduces sleep onset latency and increases sleep efficiency in randomized controlled trials, often outperforming placebo for subjective sleep quality.^[97] Despite a lower risk of tolerance compared to benzodiazepines, Z-drugs carry concerns for complex sleep-related behaviors such as sleepwalking, amnesia, and hallucinations, particularly at higher doses or in vulnerable populations.^[98] Systematic reviews indicate these adverse neuropsychiatric effects occur in up to 10% of users, underscoring the need for lowest effective dosing.^[99] Melatonin receptor agonists, such as ramelteon, promote sleep by selectively activating MT1 and MT2 melatonin receptors in the suprachiasmatic nucleus, thereby advancing circadian phase and improving sleep initiation without direct GABAergic modulation.^[100] Clinical studies show ramelteon reduces latency to persistent sleep by approximately 10-15 minutes over 5-6 weeks, with sustained efficacy in chronic insomnia patients.^[101] This class is considered safer for longer-term use, exhibiting a side effect profile comparable to placebo, including minimal risk of dependence, next-day impairment, or abuse potential, making it suitable for older adults or those with hepatic concerns.^[102] Long-term trials confirm good tolerability, with headache and dizziness as the most common mild adverse events.^[103] Orexin receptor antagonists represent a newer class, with suvorexant approved by the FDA in 2014 as the first dual orexin receptor antagonist (DORA) to treat insomnia.^[104] Subsequent approvals include lemborexant in 2019 and daridorexant in 2022, which similarly block orexin A and B from binding to OX1R and OX2R receptors, inhibiting wake-promoting pathways in the hypothalamus. By competitively blocking these receptors, suvorexant, lemborexant, and daridorexant lead to increased total sleep time and reduced wake after sleep onset in phase III trials.^[105]^[106]^[107] Post-2014 studies, including those up to 2023, demonstrate their efficacy in both sleep-onset and maintenance insomnia, with favorable safety profiles for up to 12 months, though somnolence and cataplexy-like symptoms occur in a minority of users.^[108] Unlike traditional hypnotics, this class preserves natural sleep architecture without rebound insomnia upon withdrawal.^[109] Comparative analyses, including meta-analyses of randomized trials, indicate that while pharmacological agents provide rapid short-term benefits, cognitive behavioral therapy for insomnia (CBT-I) yields superior long-term outcomes, with sustained improvements in sleep efficiency and lower relapse rates (e.g., 50-60% remission at 6-12 months versus 20-30% for drugs alone).^[110] Off-label use of certain antidepressants, such as trazodone, may be considered in cases comorbid with depression, but evidence for primary insomnia is limited and not superior to dedicated hypnotics.^[91]

Alternative and Complementary Therapies

Alternative and complementary therapies for insomnia encompass a range of non-pharmacological interventions, including herbal remedies, acupuncture, mind-body practices, and light therapy, which aim to improve sleep quality through mechanisms outside conventional medical treatments. These approaches often appeal to individuals seeking natural options, though evidence varies in strength and consistency across studies. While some randomized controlled trials (RCTs) and meta-analyses indicate modest benefits, particularly for subjective sleep improvements, rigorous long-term data remain limited. Herbal remedies such as valerian root and chamomile have been investigated for their potential to alleviate insomnia symptoms. Evidence for valerian root extracts, derived from the Valeriana officinalis plant, is mixed; some older RCTs suggested modest improvements in subjective sleep quality, though effects were more pronounced in subjective reports than objective measures like polysomnography. However, a 2024 umbrella review found insufficient evidence of efficacy for treating insomnia despite a good safety profile when used short-term, and it does not support routine use. Chamomile, often consumed as tea from Matricaria recutita flowers, has shown promise in improving sleep quality among elderly populations, with an RCT involving 60 participants reporting significant reductions in Pittsburgh Sleep Quality Index (PSQI) scores after four weeks of daily use. These herbs may act via sedative properties, such as GABA receptor modulation for valerian, but results are inconsistent across populations, with some meta-analyses noting insufficient evidence for broad recommendations. Acupuncture, a traditional Chinese medicine technique involving needle insertion at specific points, has been studied for its role in treating insomnia through potential mechanisms like endorphin release and autonomic nervous system regulation. Meta-analyses of RCTs indicate that acupuncture significantly improves sleep quality, as measured by PSQI scores, particularly after more than three weeks of treatment, with effect sizes suggesting superiority over sham acupuncture in reducing insomnia severity. For example, a review of 46 RCTs involving over 3,500 patients found acupuncture effective for chronic insomnia disorder, improving total sleep time and efficiency, though benefits may wane without ongoing sessions. The endorphin-mediated pain relief and stress reduction aspects are hypothesized to contribute to better sleep onset, but high-quality trials are needed to confirm long-term efficacy. Mind-body practices like yoga and tai chi offer structured protocols to enhance sleep by promoting relaxation and reducing hyperarousal. Yoga, involving postures, breathing, and meditation, has been evaluated in RCTs showing improvements in sleep onset latency and overall quality, with meta-analyses of 16 trials reporting significant PSQI reductions in women with sleep disturbances. Specific protocols, such as 45-60 minute sessions twice weekly for 8-12 weeks focusing on restorative poses like child's pose and savasana, yield the most consistent results. Similarly, tai chi, a gentle martial art emphasizing slow movements and mindfulness, improves sleep quality in healthy adults and those with chronic conditions, with a meta-analysis of nine RCTs demonstrating an effect size of 0.89 for PSQI improvements after 6-24 weeks of 1.5-3 hours weekly practice. These interventions may work by lowering cortisol levels and enhancing parasympathetic activity, though adherence to protocols is crucial for outcomes. Light therapy, using bright light exposure to realign circadian rhythms, has emerging evidence for insomnia in non-depressed patients, particularly those with delayed sleep phase or maintenance issues. A meta-analysis of 13 RCTs found that timed morning or evening light exposure (typically 2,500-10,000 lux for 30-60 minutes) significantly reduced wake after sleep onset and improved total sleep time compared to control conditions, without exacerbating mood symptoms in non-depressed individuals. This approach leverages the suprachiasmatic nucleus's response to light for phase advancement, offering a non-invasive option for circadian misalignment, though optimal timing varies by chronotype. Despite potential benefits, alternative therapies face limitations, including lack of regulation by the FDA for herbal products, which can lead to variability in potency and purity. The FDA does not require pre-market approval for dietary supplements like valerian or chamomile, raising concerns about contamination or inconsistent dosing. Additionally, herb-drug interactions pose risks; for example, valerian may enhance sedative effects of medications like benzodiazepines, increasing drowsiness or respiratory depression, as noted in NIH reviews of common interactions. Patients should consult healthcare providers to mitigate these risks, and while these therapies can complement approaches like CBT-I, they are not substitutes for evidence-based treatments.

Prognosis

Short-Term Outcomes

Acute insomnia, defined as sleep difficulties lasting less than three months, frequently resolves spontaneously without intervention. Studies indicate that approximately 72% of individuals experiencing acute insomnia recover normal sleep patterns, often within weeks, particularly when the underlying trigger is transient.^[111] This high rate of spontaneous remission underscores the self-limiting nature of many acute cases, where sleep disturbances subside as the precipitating factors diminish. However, about 7% of acute cases progress to chronic insomnia, highlighting the importance of early monitoring to identify those at risk.^[111] Brief interventions, such as sleep hygiene education, offer effective support for short-term recovery in acute insomnia. These approaches, which emphasize consistent sleep schedules, environmental adjustments, and avoidance of stimulants, yield notable improvements in sleep onset latency and overall efficiency. Research on behavioral self-help interventions incorporating sleep hygiene principles demonstrates rapid reductions in insomnia severity, with benefits observed within one week and sustained short-term gains in approximately 60-70% of participants reporting enhanced sleep quality.^[112] Such interventions are particularly valuable for mild to moderate acute cases, promoting quicker resolution compared to no treatment.^[113] Post-treatment relapse risks in short-term insomnia outcomes are elevated in the presence of untreated comorbidities, such as anxiety or pain disorders. Untreated co-occurring conditions can perpetuate sleep disruptions; studies indicate that approximately 27% of individuals who achieve remission of insomnia symptoms may experience relapse over time.^[114] Addressing these comorbidities concurrently reduces relapse likelihood, emphasizing integrated care for optimal short-term prognosis.^[115] Monitoring short-term outcomes typically involves sleep diaries, which track key metrics like sleep latency, duration, and efficiency over 1-3 months. These self-reported tools provide objective insights into progress, revealing patterns such as reduced wake time after sleep onset in responding individuals. Consistent diary use facilitates early detection of non-remission, guiding adjustments to interventions.^[113] Several factors influence the speed and likelihood of recovery from acute insomnia. Resolution of the precipitating stressor, such as job loss or illness, often correlates with prompt improvement, as sleep normalizes once the acute threat abates.^[116] Age also plays a role, with older adults experiencing slower recovery due to age-related changes in sleep architecture and higher comorbidity burdens, potentially extending resolution beyond the typical weeks.^[117] Younger individuals, conversely, tend to rebound more swiftly absent complicating factors.^[111]

Long-Term Implications

Persistent insomnia is associated with an elevated risk of cardiovascular diseases, including coronary heart disease and heart failure, as evidenced by cohort studies showing odds ratios ranging from 1.37 to 1.82 for incident cardiovascular events among those with chronic sleep disturbances.^[118]^[119] Similarly, insomnia contributes to a higher incidence of hypertension, with prospective data indicating an odds ratio of 1.37 for new-onset cases, potentially mediated by sympathetic nervous system activation and elevated resting heart rate.^[119] For type 2 diabetes, chronic insomnia has been linked to approximately 50% increased odds of metabolic syndrome, a key precursor, based on large-scale cohort analyses.^[120] The relationship between insomnia and mental health is bidirectional, with insomnia serving as both a precursor and consequence of depression; meta-analyses of longitudinal studies report an odds ratio of 2.60 for insomnia predicting future depression onset, while persistent insomnia in those without initial depression elevates the risk up to sixfold.^[121]^[122] In older adults, untreated insomnia is further implicated in cognitive decline and dementia, with cohort studies demonstrating faster rates of cognitive impairment and a significantly heightened risk of Alzheimer's disease, attributed to disrupted sleep's impact on amyloid-beta clearance and neuroinflammation.^[123]^[124] Effective treatments like cognitive behavioral therapy for insomnia (CBT-I) can improve long-term prognosis, with meta-analyses showing 70-80% remission rates sustained over years.^[125] Economically, the long-term effects of insomnia manifest in substantial lost productivity, with estimates from national workforce studies indicating an annual cost of $207.5 billion in the United States as of 2023 due to absenteeism and reduced performance.^[126] Globally, this burden extends into the hundreds of billions, encompassing indirect societal costs from impaired daily functioning.^[127] Meta-analyses of prospective cohorts link persistent insomnia to a 10-20% higher all-cause mortality risk, with pooled data showing a 14% increase, particularly when combined with short sleep duration, independent of comorbidities like hypertension.^[128]^[129]

Epidemiology

Prevalence and Demographics

Insomnia is a widespread sleep disorder affecting a significant portion of the global population. Estimates indicate that 10-30% of adults experience insomnia symptoms, such as difficulty initiating or maintaining sleep, while 6-10% meet the criteria for insomnia disorder according to diagnostic standards like the DSM-5 or ICSD-3.^[130] Recent systematic reviews, incorporating post-pandemic data, suggest a global prevalence of insomnia disorder around 16%, with severe cases at approximately 8%, reflecting an increase linked to stressors like COVID-19.^[131] These figures underscore the condition's substantial public health impact, though exact rates vary due to methodological differences in assessment. Demographic variations highlight disparities in insomnia prevalence. Women are disproportionately affected, with rates 1.5 to 2 times higher than in men across age groups, attributed to factors like hormonal changes and higher rates of comorbid conditions.^[132] Prevalence tends to peak in midlife (ages 35-49) and among the elderly (over 60), where up to 40-50% report symptoms, often exacerbated by age-related changes in sleep architecture and health issues.^[133] Among pediatric and adolescent populations, rates range from 15-25%, with recent trends showing increases, particularly post-2020, due to screen time and academic pressures.^[134] Regional differences further influence prevalence patterns. Urban residents often report higher rates of insomnia (around 20%) compared to rural areas (15-17%), potentially due to noise, light pollution, and lifestyle stressors, though some studies note elevated trouble falling asleep in rural settings.^[135] Prevalence appears more documented in high-income countries, where systematic surveys yield rates of 10-20%, compared to lower-middle-income regions, though underreporting in low-resource areas may skew global comparisons.^[131] Survey methodologies contribute to discrepancies in reported prevalence. Self-report tools, such as questionnaires like the Insomnia Severity Index, often yield higher estimates (up to 29%) than clinical diagnoses or interviews (around 6-12%), as individuals may overestimate sleep disturbances without objective confirmation via polysomnography.^[136] These differences highlight the need for standardized diagnostic approaches to accurately capture the disorder's true burden.^[137]

Global Trends and Disparities

The COVID-19 pandemic contributed to a notable rise in global insomnia prevalence, with studies attributing this to heightened stress, anxiety, and social isolation measures. A multinational collaborative analysis reported symptomatic insomnia rates of 36.7% and clinical insomnia disorder at 17.4% during the pandemic, representing an increase from pre-pandemic global estimates of approximately 10-15%.^[138] Similarly, an international review estimated the average prevalence of post-COVID-19 insomnia at around 24%, with persistence observed in long COVID cases.^[139] These trends highlight a 20-30% relative uptick in affected populations in various regions, exacerbating the overall burden.^[140] Socioeconomic disparities amplify the insomnia burden, with higher prevalence observed among low-income groups due to factors like financial strain and unstable living conditions. Research indicates that lower socioeconomic status correlates with increased insomnia risk, including shorter sleep duration and poorer quality, particularly in urban low-SES communities.^[141] In developing regions, limited healthcare infrastructure further restricts access to diagnosis and treatment, resulting in untreated cases and compounded health impacts.^[142] Racial and ethnic minorities within these groups often face intersecting vulnerabilities, such as neighborhood social vulnerability, which mediates higher odds of insomnia disorder.^[143] Cultural influences play a role in under-reporting insomnia worldwide, as stigma in certain societies portrays sleep issues as personal weaknesses or moral failings, deterring individuals from seeking help. Qualitative studies reveal that internalized and anticipated stigma is linked to self-reported sleep deficiencies, including insomnia symptoms, across diverse cultural contexts.^[144] This is particularly evident in collectivist cultures where mental health discussions, including sleep, remain taboo, leading to lower detection rates.^[145] Access to insomnia care varies globally, with under-diagnosis common in primary care settings where providers often overlook sleep complaints unless explicitly raised by patients.^[146] Post-2020 telehealth expansions have mitigated some barriers, enabling remote delivery of evidence-based interventions and improving outcomes in underserved areas.^[147] Systematic reviews confirm telemedicine's efficacy in treating insomnia, with positive effects on sleep parameters comparable to in-person care.^[148] Policy efforts address these disparities through international frameworks integrating sleep health into mental health priorities. The World Health Organization's Comprehensive Mental Health Action Plan 2013–2030 emphasizes holistic approaches that include sleep promotion to enhance global mental well-being, though implementation remains uneven across low-resource settings.^[149] Additional calls advocate for public health policies targeting sleep education and equitable access to reduce the insomnia gap.^[150]

Society and Culture

Historical Perspectives

In ancient times, descriptions of insomnia, referred to as "sleeplessness," appeared in early medical texts, with Hippocrates around 400 BC linking it to imbalances in the body's humors, such as excess bile or phlegm disrupting natural rest.^[151] Hippocratic physicians viewed insomnia as a symptom of broader physiological disturbances and recommended soporific remedies, like herbal concoctions, to restore humoral equilibrium and promote sleep, though specific formulations were not detailed in surviving writings.^[152] This humoral theory dominated Western medical thought on sleep disorders for centuries, framing insomnia as a treatable imbalance rather than a standalone condition.^[153] By the 19th and early 20th centuries, insomnia emerged as a recognized psychiatric entity, often classified under neuroses or anxiety-related disorders in emerging psychiatric nosologies.^[154] The introduction of barbiturates in the early 1900s, starting with barbital in 1903, marked a pharmacological shift, positioning these sedatives as primary treatments for insomnia due to their ability to induce sleep in psychiatric patients.^[155] However, their narrow therapeutic index led to widespread risks, including overdose deaths and dependency, prompting caution in clinical use by the mid-20th century as reports of toxicity accumulated.^[156] The mid-20th century witnessed a pivotal shift toward sleep medicine as a distinct field, driven by electroencephalogram (EEG) discoveries that revealed sleep's physiological stages. In the 1950s, researchers like Eugene Aserinsky and Nathaniel Kleitman identified rapid eye movement (REM) sleep through EEG monitoring, demonstrating cyclical brain activity patterns and challenging prior psychiatric views of insomnia as purely psychological.^[157] This work, building on earlier EEG observations of non-REM stages in the 1930s, established sleep as a measurable neurobiological process, laying the foundation for polysomnography and specialized clinics by the 1970s.^[158] From the 1980s to the 2000s, cognitive behavioral therapy for insomnia (CBT-I) evolved as a non-pharmacological intervention, integrating techniques like stimulus control and sleep restriction, with key developments in the late 1980s formalizing its structured protocol.^[159] Concurrently, Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications refined insomnia's nosology: DSM-III (1980) introduced it as a separate disorder, DSM-III-R (1987) specified diagnostic criteria, and DSM-IV (1994) distinguished primary insomnia from comorbid forms, emphasizing duration and impairment.^[160] These advancements highlighted insomnia's chronic nature and behavioral underpinnings. In recent milestones, the 1998 discovery of orexin neuropeptides, which regulate wakefulness, spurred development of orexin receptor antagonists; suvorexant, the first such drug, gained FDA approval in 2014 for insomnia treatment, offering a targeted mechanism distinct from traditional sedatives.^[161]

Public Awareness and Stigma

Public awareness of insomnia has grown in recent decades, yet misconceptions persist, often portraying it in media as a mere nuisance rather than a serious health condition. In films and literature, insomnia is frequently depicted as a hindrance to productivity, with sleepless characters grappling with impaired focus and daily functioning amid modern life's demands, as seen in Hollywood narratives where it symbolizes the toll of relentless ambition.^[162] For instance, in science fiction works, sleep deprivation underscores themes of consciousness and survival, while in modernist literature like Franz Kafka's writings, it both torments and fuels creative output, though rarely shown as treatable.^[163] Occasionally, media uses insomnia for comic relief, exaggerating symptoms in comedies to highlight quirky exhaustion, which minimizes its clinical reality and reinforces stereotypes of it as a personal failing rather than a disorder.^[164] Stigma surrounding insomnia significantly impacts help-seeking behaviors, with many perceiving it as a sign of weakness or laziness, leading to under-reporting and delayed treatment. Studies indicate that up to 81% of individuals with chronic insomnia disorder experience stigma, including internalized shame and enacted discrimination, which correlates with longer illness duration and poorer mental health outcomes.^[145] This perception contributes to reluctance in discussing sleep issues with clinicians, with approximately 30% of those affected hesitating due to stigma and 45% avoiding medication options, exacerbating the condition's untreated prevalence.^[165] Such barriers, rooted in societal biases, not only prolong suffering but also widen health disparities, as stigmatized individuals often dismiss symptoms as temporary stress rather than seeking professional care.^[166] Advocacy efforts by organizations like the National Sleep Foundation have aimed to combat these issues through targeted campaigns, such as Sleep Awareness Week held annually in March, which educates the public on sleep's role in well-being, productivity, and happiness.^[167] These initiatives highlight research showing poor sleep doubles risks to work performance and social life, encouraging lifestyle changes and policy advocacy to normalize sleep health discussions.^[168] On the economic and policy front, insomnia features prominently in workplace wellness programs, where employers implement sleep hygiene education, flexible scheduling, and cognitive behavioral therapy for insomnia to reduce absenteeism costs—estimated at over $2,000 per untreated employee annually—and boost overall productivity.^[169] Such programs, supported by guidelines from bodies like the CDC, reflect growing recognition of insomnia's role in occupational health, with over half of large U.S. employers planning expansions by 2021.^[170] Cultural variations further shape perceptions of insomnia, influencing how it is framed as an individual versus communal concern. European surveys reveal similar disparities; for example, UK respondents report greater work-related impacts (85%) compared to French individuals (lower relational effects at 51%), with overall trivialization delaying care across regions.^[171] These differences underscore the need for culturally tailored awareness to address insomnia effectively.

References

[1]
Insomnia - Symptoms and causes - Mayo Clinic
Jan 16, 2024 · Insomnia is a common sleep disorder that can make it hard to fall asleep or stay asleep. It also can cause you to wake up too early and not be able to get back ...
[2]
What Is Insomnia? - NHLBI - NIH
Mar 24, 2022 · Insomnia is a common sleep disorder. With insomnia, you may have trouble falling asleep, staying asleep, or getting good quality sleep.Insomnia - Treatment · Symptoms · Living With Insomnia · Causes and Risk Factors
[3]
Insomnia: Definition, Prevalence, Etiology, and Consequences - NIH
Insomnia is defined by the presence of an individual's report of difficulty with sleep. For example, in survey studies, insomnia is defined by a positive ...
[4]
Insomnia: Symptoms, Causes, and Treatments - Sleep Foundation
Jul 4, 2025 · Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, or both, even if you have ample time and a bedroom environment ...What Causes Insomnia? · Insomnia and Women · Treatments for Insomnia
[5]
[PDF] Insomnia - American Academy of Sleep Medicine
An insomnia disorder is defined as a persistent difficulty with sleep initiation, duration, or consolidation that occurs despite adequate opportunity and ...
[6]
Table 3.36, DSM-IV to DSM-5 Insomnia Disorder Comparison - NCBI
Difficulty initiating sleep. · Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. · Early-morning ...
[7]
[PDF] New Guideline - American Academy of Sleep Medicine
>30 minutes, wake after sleep onset >30 minutes, sleep effi- ciency <85%, and/or total sleep time <6.5 hours.19,20 Day-to-day variability should be ...
[8]
Insomnia and daytime functioning - ScienceDirect.com
A number of studies have found that people with insomnia self-report daytime symptoms such as elevated fatigue, mood disturbance and reduced quality of life.
[9]
Cognitive Impairment in Individuals with Insomnia - Oxford Academic
The aims of this study were to (1) investigate the nature of cognitive impairment in individuals with insomnia, (2) document their clinical significance, ...Cognitive Impairment In... · Methods · Measures Of Sleep<|control11|><|separator|>
[10]
Cognitive Dysfunction in Insomnia Phenotypes: Further Evidence for ...
Jul 18, 2021 · Both insomnia groups had poorer self-reported attention, memory, mood, and sleep, and poorer laboratory-assessed attention (inconsistency).
[11]
Impaired emotional memory and decision-making following primary ...
Moreover, insomnia can lead to impairments of many basic cognitive functions, including learning and memory, attention,[5,6] as well as emotional impairments.
[12]
The Relation between Insomnia Symptoms, Mood, and Rumination ...
In the first study, poor sleepers reported significantly higher levels of daytime symptom rumination than did good sleepers. Across both studies, rumination ...
[13]
Associations between Insomnia Symptoms and Anxiety ... - NIH
Oct 18, 2022 · Stepwise analyses revealed that daytime dysfunction and dissatisfaction were most consistently related to anxiety symptoms. Greater attention ...
[14]
Depression and Sleep Disturbances: Common Bedfellows
Apr 19, 2018 · Poor sleep typically causes next-day symptoms of morning tiredness, daytime fatigue, concentration and attention problems, and irritable mood, ...
[15]
Treating the Health, Quality of Life, and Functional Impairments in ...
Results: Insomnia patients report a variety of symptoms, including daytime sleepiness, fatigue, cognitive impairment, symptoms of de- pression, anxiety, health ...
[16]
Sleep Dysfunction and Gastrointestinal Diseases - PMC
It is possible that sleep deprivation leads to an increase in microscopic inflammation in the bowel, which may, in turn, result in gastrointestinal symptoms.
[17]
The Effects of Sleep on Workplace Cognitive Failure and Safety - NIH
Our results suggest that workers with more insomnia symptoms on average reported engaging in fewer required and voluntary safety behaviors and were at a greater ...
[18]
https://pmc.ncbi.nlm.nih.gov/articles/PMC4153057
[19]
Exploring the social context of insomnia: a thematic content analysis ...
Participants described that their insomnia contributed to conflicts in their romantic relationships and created tense situations with their co-workers and ...Abstract · Introduction · Results · Discussion<|control11|><|separator|>
[20]
The Insomnia Severity Index: Psychometric Indicators to Detect ... - NIH
The Insomnia Severity Index (ISI) is a brief instrument that was designed to assess the severity of both nighttime and daytime components of insomnia ...
[21]
Insomnia disorder: State of the science and challenges for the future
Apr 22, 2022 · ... impaired cognitive functioning, irritability, anxiety and low mood are key daytime impairments. Insomnia disorder is well acknowledged in ...
[22]
A Behavioral Perspective on Insomnia Treatment - PubMed
The major behavioral treatments of insomnia--progressive relaxation, biofeedback, cognitive approaches, stimulus control instructions, chronotherapy, and sleep ...
[23]
The Pathophysiology of Insomnia - PMC - PubMed Central
Conditioned arousal is the repeated association of sleep-related cues with wakefulness and/or arousal, which, over time, results in an arousal response when a ...
[24]
Identifying safety behaviors in insomnia - PubMed
Safety behaviors have been identified as contributing to the maintenance of anxiety disorders. They include overt or covert strategies designed to prevent a ...
[25]
Safety behaviors and sleep effort predict sleep disturbance and ...
Jan 11, 2014 · Sleep-related safety behaviors and sleep effort were both significantly associated with the severity of sleep disturbance among people with ...
[26]
Electronic Screen Use and Sleep Duration and Timing in Adults
Mar 27, 2025 · Exposure to bright lights before sleep can delay the release of melatonin, therefore increasing sleep latency and disrupting circadian rhythm.
[27]
Electronic Screen Use and Sleep Duration and Timing in Adults - PMC
Mar 27, 2025 · Exposure to bright lights before sleep can delay the release of melatonin, therefore increasing sleep latency and disrupting circadian rhythm.
[28]
The heritability of insomnia: A meta‐analysis of twin studies - Barclay
Nov 21, 2020 · Numerous twin studies have concurred that insomnia stems from a combination of genetic and environmental factors, although heritability ...
[29]
The heritability of insomnia: A meta-analysis of twin studies - PubMed
Dec 3, 2020 · Our meta-analysis provides a robust estimate of the heritability of insomnia, which can inform future research aiming to uncover molecular genetic factors.Missing: predisposing 30-50%
[30]
Genetic Pathways to Insomnia - MDPI
This review summarizes current research on the genetics of insomnia, as genetic contributions are thought to be important for insomnia etiology.4.1. Candidate Gene · 4.2. Genome-Wide Association... · 5. Conclusions And Future...
[31]
Circadian Rhythms, Sleep, and Disorders of Aging - PMC
Aging is associated with decreased circadian rhythmicity of behaviors including sleep. Age impacts sleep timing, duration, and consolidation.Circadian Rhythms, Sleep... · Aging Of The Sleep System · Sleep Promotes Clearance Of...
[32]
Insomnia in women approaching menopause: beyond perception
The menopause transition is marked by increased prevalence in disturbed sleep and insomnia, present in 40–60% of women.
[33]
Chronic Insomnia - StatPearls - NCBI Bookshelf
Mar 28, 2025 · Chronic insomnia, defined as trouble falling asleep or staying asleep at least 3 nights a week for 3 months or longer, affects individuals of all ages, with a ...
[34]
Biological Factors of Insomnia | Stanford Health Care
Conditions that are associated with difficulty breathing, such as asthma, congestive heart failure, chronic obstructive pulmonary diseases, and sleep apnea.Missing: respiratory | Show results with:respiratory
[35]
https://pubmed.ncbi.nlm.nih.gov/15600224/
[36]
Precipitating factors of insomnia - PubMed - NIH
The most common precipitating factors of insomnia were related to family, health, and work-school events. Sixty-five percent of precipitating events had a ...
[37]
The Association between Traumatic Life Events and Insomnia ... - NIH
Trauma exposure likely contributes to poor sleep, but relatively few studies have empirically tested this, instead focusing on posttraumatic stress disorder.
[38]
[PDF] for historical Reference Only - NHLBI
pressants, steroids, decongestants, beta blockers, caffeine, alcohol, nicotine, and recreational drugs. Insomnia associated with specific sleep disorders.Missing: triggers | Show results with:triggers
[39]
Insomnia - Causes and Risk Factors | NHLBI, NIH
Mar 24, 2022 · Environment or occupation · Shift or night work · Noise or light during the night · Uncomfortably high or low temperatures. Traveling often to ...Missing: precipitating | Show results with:precipitating
[40]
Insomnia Overview: Epidemiology, Pathophysiology, Diagnosis and ...
Precipitating factors may include an increasing burden of health problems with sleep-disruptive symptoms (eg, nocturia, dyspnea, pain), lifestyle changes after ...
[41]
Insomnia: What It Is, Causes, Symptoms & Treatment
Insomnia is when you experience disruptions in how you feel or function because you aren't sleeping well or sleeping enough.
[42]
The natural history of insomnia: predisposing, precipitating, coping ...
The findings add weight to Spielman's 3P model of insomnia in terms of the relevance of these factors over the early developmental course of insomnia.
[43]
Transient Insomnia Versus Chronic Insomnia: A Comparison Study ...
Jun 24, 2013 · Dysfunctional beliefs regarding worry about insomnia and cognitive arousal were predictors for chronic insomnia. Sleep-related safety behavior, ...
[44]
Review Article - :: Sleep Medicine Research
Dec 31, 2011 · Chronic insomnia occurs as a result of maladaptive coping behaviors (perpetuating factors). Predisposing factors include: trait hyperarousal ...Missing: scholarly | Show results with:scholarly
[45]
[PDF] Models of Insomnia
The secondary factor is designated as sleep stimuli as conditioned stimuli. This is meant to represent when sleep stimuli become conditioned stimuli for ...
[46]
[PDF] Insomnia - BINASSS
Once conditioned, hyperarousal becomes a perpetuating factor that persists long after precipitating events cease to play a role in elevating stress. This.
[47]
Behavioral interventions for insomnia: Theory and practice - PMC
This article presents an overview of behavioral interventions for insomnia. Behavioral interventions for insomnia include relaxation training, stimulus ...
[48]
Insomnia, anxiety and related disorders: a systematic review on ...
This review represents a comprehensive overview of clinical and therapeutic approaches to insomnia in the framework of anxiety and related disorders
[49]
Sleep disturbances in generalized anxiety Disorder: The central role ...
The relationship between insomnia and GAD is increasingly supported by neurobiological evidence. Both involve chronic hyperarousal of the HPA axis, with ...<|control11|><|separator|>
[50]
The role of the GABAergic system on insomnia - PMC
Mar 26, 2024 · Many studies have demonstrated that GABA levels correlate with sleep quality, suggesting that modulating the GABAergic system may be a promising therapeutic ...
[51]
Sleep, Insomnia, and the Orexin System - Psychiatrist.com
Sep 15, 2013 · Some evidence does suggest that GABA levels in the brain are lower in patients with insomnia than in those without insomnia. For example, Dr ...Missing: imbalances | Show results with:imbalances
[52]
The increased functional connectivity between the locus coeruleus ...
The hyperarousal theory, which proposes increased activation in specific brain regions in insomniacs, is largely recognized as an explanation for the origin of ...
[53]
The relationship between insomnia and body temperatures - PubMed
Sleep maintenance insomnia has been associated not with a circadian rhythm timing abnormality, but with nocturnally elevated core body temperature.
[54]
Neurophysiology of Sleep and Wakefulness: Basic Science and ...
This relationship is described as a bistable, “flip-flop” circuit, in which the two halves of the circuit strongly inhibit each other to produce two stable ...The Vlpo And The Sleep State · Circadian Sleep Regulation · Circadian Rhythm Sleep...
[55]
A cognitive model of insomnia - ScienceDirect.com
August 2002, Pages 869-893. Behaviour Research and Therapy. A cognitive model of insomnia. Author links open overlay panelA.G Harvey. Show more. Add to Mendeley.
[56]
A cognitive model of insomnia - PubMed
A cognitive model of insomnia. Behav Res Ther. 2002 Aug;40(8):869-93. doi: 10.1016/s0005-7967(01)00061-4. Author. A G Harvey. Affiliation. 1 Department of ...
[57]
The Role of Insomnia-Specific Rumination - PubMed
In insomnia, specific rumination is related to both trait predisposition to arousal and to state-dependent arousal. It is also related to emotion dyregulation.Missing: studies | Show results with:studies
[58]
Psychometric properties of the Pre-Sleep Arousal Scale in a large ...
Among those with insomnia, a shortened PSAS (PSAS-14) was established, which consisted of a cognitive and a somatic subscale (48.6% of the variance). The PSAS- ...
[59]
Clinical Guideline for the Evaluation and Management of Chronic ...
An expert insomnia panel was assembled by the AASM to author this clinical guideline. In addition to using all AASM practice parameters and AASM Sleep ...
[60]
https://icd.who.int/browse11/l-m/en
[61]
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1625107144
[62]
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1625107150
[63]
Sleep Deprivation and Deficiency - Healthy Sleep Habits - NHLBI
Mar 24, 2022 · Go to bed and wake up at the same time every day. · Try to keep the same sleep schedule on weeknights and weekends. · Use the hour before bed for ...Missing: modifications consistent
[64]
Behavioral Strategies, Including Exercise, for Addressing Insomnia
Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations. Set a bedtime that is early enough for you to get at ...
[65]
Sleep tips: 6 steps to better sleep - Mayo Clinic
1. Stick to a sleep schedule. Set aside no more than eight hours for sleep. · 2. Pay attention to what you eat and drink. Don't go to bed hungry or stuffed. · 3.Missing: modifications | Show results with:modifications
[66]
Bedroom Environment: What Elements Are Important?
Jul 10, 2025 · Studies have shown people simply sleep better when their bedroom is optimized for temperature, noise and light levels, and comfort.Temperature · Light · Additional Tips For A...<|control11|><|separator|>
[67]
Healthy sleep practices for shift workers: consensus sleep hygiene ...
Create a comfortable sleep environment Aim to sleep somewhere that is:Comfortably cool: 16–20ºC/ 60–68ºF with adequate ventilation.Dark: block out as much light ...
[68]
Nutrition and Sleep: Diet's Effect on Sleep
Jul 11, 2025 · Both caffeine and alcohol have been found to reduce sleep quality, especially if taken within two to three hours before bedtime.
[69]
Insomnia - Treatment | NHLBI, NIH
Mar 24, 2022 · Avoid naps, especially in the afternoon. This may help you sleep longer at night. Eat meals on a regular schedule and avoid late-night dinners.Missing: consistent | Show results with:consistent
[70]
How Can Exercise Affect Sleep? - Sleep Foundation
Jul 29, 2025 · So while exercising before bedtime may not be inherently harmful, vigorous workouts in the hour leading up to bed can affect sleep efficiency ...
[71]
The Effect of Physical Activity on Sleep Quality and Sleep Disorder
Aug 16, 2023 · Regular physical activity can lead to improved sleep quality, reduced sleep latency, and better overall sleep quality.
[72]
Insomnia - Diagnosis and treatment - Mayo Clinic
Jan 16, 2024 · This disorder can make it hard to fall asleep, hard to stay asleep or both, even though you have the chance for enough sleep.Symptoms and causes · Insomnia - Care at Mayo Clinic · Prescription sleeping pills
[73]
Relaxation Techniques: What You Need To Know | NCCIH - NIH
Jun 8, 2021 · Progressive Relaxation: Also called progressive muscle relaxation, this technique involves tensing different muscles in your body and then ...
[74]
Relaxation Exercises to Help Fall Asleep - Sleep Foundation
Jul 24, 2025 · Progressive Muscle Relaxation. Progressive muscle relaxation is based on the idea that it's hard to be tense when your muscles are relaxed.Breathing Exercises · Visualization ExercisesMissing: prevent | Show results with:prevent
[75]
Progressive muscle relaxation alleviates anxiety and improves sleep ...
Apr 30, 2024 · PMR can enhance both physical and mental relaxation by diminishing sympathetic nervous system activity, thereby reducing anxiety and stress ...Missing: prevent | Show results with:prevent
[76]
Prevention is better than cure: why early interventions for insomnia ...
Hybrid school-based interventions, combining elements from sleep- and pain-focused prevention programs, might be a viable method to prevent insomnia and chronic ...
[77]
A Mindfulness-Based Approach to the Treatment of Insomnia - PMC
Mindfulness-based therapy for insomnia includes reducing unwanted wakefulness at night and effectively managing the emotional reactions to sleep disturbance ...
[78]
Association between sleep-related worry and trait mindfulness ... - NIH
Jul 1, 2025 · The present study suggested that mindfulness might play a protective role against sleep-related worry among shift nurses as a psychobehavioral ...
[79]
Impact of Mindfulness-Based Stress Reduction on sleep-related ...
The results suggest that participating in MBSR enhances sleep quality and practicing mindfulness may contribute to reducing cognitive arousal.Missing: shift | Show results with:shift
[80]
Insomnia in Older Adults - PMC - NIH
Insomnia screening is important as it facilitates early intervention with behavioral management, reduces the potential for pharmacological management, which ...
[81]
Insomnia in older adults: A review of treatment options
Jan 1, 2025 · Aging is associated with circadian rhythm changes, with the main change being phase advance, in which older adults have an earlier onset of ...Antidepressants And... · Melatonin And Melatonin... · Dual Orexin Receptor...
[82]
Effect of a behavioral-educational sleep intervention for first-time ...
Aug 15, 2020 · Prenatal sleep guidance and postnatal follow-up appears to enhance nocturnal sleep of mothers, change their perceptions of their own sleep, and increase ...
[83]
Brief behavioral treatment for insomnia decreases trauma-related ...
Cognitive behavioral therapy for insomnia (typically 6–8 sessions) has been shown to reduce trauma-related nightmares.Missing: prevent | Show results with:prevent
[84]
Acute sleep interventions as an avenue for treatment of trauma ...
For posttrauma symptoms persisting beyond 2 days, existing guidelines recommend a brief 4- to 5-session trauma-focused cognitive behavioral therapy with ...
[85]
Effects of a brief behavioral treatment for PTSD-related sleep ...
Conclusions. A very brief behavioral intervention targeting post-traumatic nightmares and insomnia was associated with significant improvements in sleep and ...Missing: prevent | Show results with:prevent
[86]
Prevention of fatigue and insomnia in shift workers—a review of non ...
Aug 2, 2016 · The most common non-pharmacological recommendations to improve sleep quality and to reduce insomnia and fatigue were scheduling, bright light exposure, napping ...
[87]
Current sleep interventions for shift workers: a mini review to shape ...
Adjustments to shift schedules and changes to workplace lighting have been shown to mitigate the effects of shift work-related circadian misalignment; however, ...
[88]
A Smartphone App for Adolescents With Sleep Disturbance - NIH
Jul 28, 2017 · The Sleep Ninja is a fully-automated app that delivers CBT-I to young people, incorporating the features and information that young people reported they would ...
[89]
Youth screen media habits and sleep - PubMed Central - NIH
90% of included studies found an association between screen media use and delayed bedtime and/or decreased total sleep time.
[90]
Pharmacological Management of Insomnia - PMC - PubMed Central
Feb 1, 2021 · This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles.
[91]
Benzodiazepines - StatPearls - NCBI Bookshelf - NIH
Benzodiazepine administration may lead to common adverse effects, including, but not limited to, respiratory depression, respiratory arrest, drowsiness, ...
[92]
Temazepam - StatPearls - NCBI Bookshelf - NIH
Jan 11, 2024 · Temazepam, a benzodiazepine, belongs to the same category and carries similar risks for patients, such as overdose, respiratory depression, ...
[93]
Benzodiazepines: Uses, Dangers, and Clinical Considerations - PMC
Nov 10, 2021 · Regular use of BZDs has been shown to cause severe, harmful psychological and physical dependence, leading to withdrawal symptoms similar to ...
[94]
Long-term use of benzodiazepines in chronic insomnia: a European ...
The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use ...
[95]
Zolpidem - StatPearls - NCBI Bookshelf
Drug overdose with zolpidem involves CNS depression, cognitive impairments leading to drowsiness or coma, cardiovascular and respiratory depression, and other ...
[96]
Zolpidem: Efficacy and Side Effects for Insomnia - PMC
Zolpidem is a helpful drug for the treatment of insomnia in conjunction with cognitive-behavioral therapy. Like all drugs, it does have some side effects.
[97]
Adverse Reactions to Zolpidem: Case Reports and a Review of the ...
Zolpidem has been associated with the development of adverse neuropsychiatric reactions, such as hallucinations/sensory distortion, amnesia, sleepwalking/ ...
[98]
The Clinical and Forensic Toxicology of Z-drugs - PMC
Z-drug-induced neuropsychiatric adverse effects such as hallucinations and psychosis have been described for over 15 years, particularly with zolpidem [36–38].
[99]
Ramelteon: A Novel Hypnotic Indicated for the Treatment of Insomnia
Ramelteon is a hypnotic with a novel mechanism of action and is the only melatonin agonist currently indicated for the treatment of insomnia.
[100]
Efficacy and Safety of 6-Month Nightly Ramelteon Administration in ...
Ramelteon is the first melatonin-receptor agonist approved in the United States for the treatment of insomnia and has a mechanism of action that differs ...
[101]
Critical appraisal of ramelteon in the treatment of insomnia - PMC
Overall, ramelteon is safe and well tolerated, although some questions remain regarding its long-term efficacy and safety. These issues and possibilities for ...
[102]
Pharmacotherapy of Insomnia with Ramelteon: Safety, Efficacy and ...
Apr 12, 2011 · Ramelteon is both a chronobiotic and a hypnotic that has been shown to promote sleep initiation and maintenance in various preclinical and in clinical trials.
[103]
Suvorexant: The first orexin receptor antagonist to treat insomnia
Suvorexant, the first in a new class of drugs to treat insomnia by targeting the orexin receptors, has been approved recently, on 13 August, 2014.Missing: post- | Show results with:post-
[104]
Suvorexant, a Dual Orexin Receptor Antagonist for the Management ...
Suvorexant is a potent dual orexin receptor antagonist that blocks both OX1R and OX2R. It promotes sleep through the binding inhibition of orexin A and B.Missing: post- | Show results with:post-
[105]
Suvorexant, a Novel Dual Orexin Receptor Antagonist, for the ...
Jan 28, 2023 · Suvorexant, is an orexin receptor antagonist used for the treatment of insomnia, characterized by difficulties with sleep onset and/or sleep ...
[106]
Suvorexant in insomnia: efficacy, safety and place in therapy - PMC
Suvorexant is effective at decreasing sleep latency and increasing total sleep time, much like traditional sleep agents.Pharmacology · Pharmacokinetics · Efficacy: Summary Of Key...
[107]
Comparative effectiveness of cognitive behavioral therapy for ...
May 25, 2012 · Conclusions. CBT-I is effective for treating insomnia when compared with medications, and its effects may be more durable than medications. ...
[108]
The Natural History of Insomnia: the incidence of acute ... - NIH
The primary aim of the present study was to estimate the incidence per annum of acute insomnia and to what extent those that develop acute insomnia recover ...
[109]
An online behavioral self-help intervention rapidly improves acute ...
Mar 2, 2024 · An online behavioral self-help intervention rapidly reduces acute insomnia severity (within 1 week), and benefits mood in people with acute insomnia.Materials And Methods · Results · Outcomes
[110]
Behavioral and psychological treatments for chronic insomnia ...
This guideline establishes clinical practice recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults.
[111]
Comorbid Insomnia and Psychiatric Disorders: An Update - PMC
Insomnia can also be comorbid with other psychiatric disorders, thereby adding to the medical burden and increasing the risk of psychiatric relapse.
[112]
Insomnia: Practice Essentials, Background, Epidemiology
Feb 11, 2025 · Specific criteria vary, but common ones include taking longer than 30 minutes to fall asleep, staying asleep for less than 6 hours, waking more ...
[113]
Insomnia in the Older Adult - PMC
Risk factors of Insomnia ... Multiple factors increase the risk for older adults developing insomnia. They include environmental, behavioral, medical, and social ...Insomnia In The Older Adult · Introduction · Table 1
[114]
Sleep patterns and cardiovascular disease risk in US participants
Jan 9, 2025 · Participants with poor sleep patterns had a significantly higher risk of CVD (OR = 1.82, 95% CI: 1.52–2.16, p < 0.001). Self-reported trouble ...
[115]
Associations of Sleep-disordered Breathing and Insomnia with ...
Insomnia was associated with incident hypertension (odds ratio, 1.37; 95% CI, 1.11–1.69) but not with diabetes. The association between insomnia and incident ...<|separator|>
[116]
Sleep and Cardiometabolic Health: A Narrative Review of ...
Sep 26, 2025 · Habitual short sleep predicts higher incidence of metabolic syndrome and type 2 diabetes, while chronic insomnia is linked to 45% greater odds ...
[117]
Insomnia as a predictor of depression: A meta-analytic evaluation of ...
The random-effects model showed an overall odds ratio for insomnia to predict depression of 2.60 (confidence interval [CI]: 1.98–3.42). When the analysis was ...
[118]
The Bidirectional Association Between Depression and Insomnia
Participants who did not have depression in HUNT2 but who had insomnia in both HUNT2 and HUNT3 had an odds ratio (OR) of 6.2 of developing depression at HUNT3.
[119]
Chronic Insomnia Linked to Cognitive Decline and Elevated ...
Oct 1, 2025 · Older adults with chronic insomnia experience a faster rate of cognitive decline and are at higher risk of developing cognitive impairment, ...
[120]
The association between insomnia and cognitive decline: A scoping ...
The results revealed a significantly increased risk of cognitive decline or Alzheimer's disease among patients with insomnia.
[121]
Insomnia costing U.S. workforce $63.2 billion a year in lost ...
Aug 18, 2017 · As a nation, the total cost is 252.7 days and $63.2 billion. “We were shocked by the enormous impact insomnia has on the average person's life,” ...Missing: burden | Show results with:burden
[122]
Insomnia: The Multibillion-Dollar Problem Sapping World Productivity
Sep 8, 2023 · ... Impact of Insomnia on Global Populations. Mar 17, 2023 · Project. The societal and economic burden of insomnia in adults: An international study.
[123]
Incidence of adverse cardiovascular events in patients with insomnia
Sep 21, 2023 · Pooled analysis of 9 studies reported 14% increased risk of all-cause mortality in our study. Our results were confirmed by a meta-analytic ...
[124]
Association Between Insomnia Symptoms and Mortality | Circulation
Nov 13, 2013 · Some insomnia symptoms, especially difficulty initiating asleep and nonrestorative sleep, are associated with a modestly higher risk of mortality.
[125]
Insomnia: Definition, Prevalence, Etiology, and Consequences
Chronic insomnia is highly prevalent and affects approximately 30% of the general population. Insomnia impairs cognitive and physical functioning and is ...<|control11|><|separator|>
[126]
Estimation of the global prevalence and burden of insomnia
The ten countries that had the highest estimated prevalence of insomnia disorder were Bangladesh, Brazil, China, India, Indonesia, Mexico, Nigeria, Pakistan, ...
[127]
Gender Difference in the Prevalence of Insomnia: A Meta-Analysis of ...
Nov 19, 2020 · Conclusions: This meta-analysis found that the prevalence of insomnia in females was significantly higher than males in the included studies.
[128]
Insomnia and Older Adults - Sleep Foundation
Jul 10, 2025 · Want to learn more about insomnia in seniors? This guide discusses causes, symptoms, and treatment for insomnia and other sleep disorders in ...
[129]
Insomnia in Childhood and Adolescence | IntechOpen
Insomnia affects 20–30% of the juvenile and adolescent population at different life stages [11].
[130]
Urban-rural differences in the prevalence and influencing factors of ...
Urban residents exhibited a significantly higher insomnia rate (19.73%) compared to rural residents (16.99%). Logistic regression analysis indicated that among ...
[131]
Insomnia symptom prevalence in England: a comparison of cross ...
May 7, 2024 · We found that 29% of the sample self-reported having insomnia symptoms, while only 6% had a Read code for insomnia symptoms in their primary care records.
[132]
The Prevalence of Insomnia Disorder in the General Population: A ...
May 14, 2025 · They observed that 10%–15% of the population reported insomnia with daytime symptoms, and 6%–10% suffered from insomnia according to the strict ...
[133]
Prevalence of Insomnia at Before and During the COVID-19 Pandemic
Jun 30, 2023 · Lockdown, social confinement, and the uncertainty of the COVID-19 pandemic have increased mental health disorders and affected sleep disorders, ...Missing: global trends post-
[134]
Long-term Effects of COVID-19 on Sleep Patterns
Jan 2, 2025 · The average prevalence of post-COVID-19 insomnia is estimated at approximately 24%.21 However, few studies document its time course. A ...Missing: global | Show results with:global
[135]
Pre-existing and post-pandemic insomnia symptoms are associated ...
The coronavirus disease 2019 (COVID-19) pandemic has led to an increased prevalence of insomnia and mental health symptoms globally.
[136]
Socioeconomic status and sleep duration among a representative ...
Dec 18, 2024 · Higher poverty, education, and food security all predict higher prevalences of insufficient workday and non-workday sleep. Second, these ...
[137]
Race and Socioeconomic Status: Interlinked Drivers of Sleep Health ...
May 30, 2023 · Insomnia is the second most common sleep disorder in veterans, with an incidence that varies between 30% and 57%, versus 30% in the general ...
[138]
Neighborhood social vulnerability as a mediator of racial disparities ...
Oct 29, 2024 · Our results showed that Black Americans with an insomnia disorder had over 3 times the odds of living in neighborhoods with greater social ...
[139]
Adapting the Health Stigma & Discrimination Framework to ... - NIH
We found consistent evidence that stigma, whether internalized, perceived, or anticipated, is associated with self-reported characteristics of sleep deficiency.
[140]
The stigma of patients with chronic insomnia: a clinical study - PMC
Jul 5, 2022 · The objective of this study was to explore the stigma and related influencing factors in individuals with chronic insomnia disorder (CID).
[141]
Provider perspectives of implementation of an evidence-based ...
Nov 30, 2020 · If patients brought up insomnia during appointments, primary care physicians commonly referred them for further evaluation and treatment.<|separator|>
[142]
Increasing access to evidence-based insomnia care in the United ...
Jason Ong, PhD, discussed the positive role that technology and telehealth can play in improving access to high-quality care for insomnia disorder.
[143]
Telemedicine and insomnia: a comprehensive systematic review ...
A systematic review of 16 selected studies showed that telemedicine interventions have a positive effect on improving insomnia in different groups.
[144]
Mental health - World Health Organization (WHO)
Oct 8, 2025 · All WHO Member States have committed to the Comprehensive mental health action plan 2013–2030, which aims to improve mental health through four ...Missing: sleep | Show results with:sleep
[145]
The need to promote sleep health in public health agendas across ...
To improve sleep health across the globe, a focus on education and awareness, research, and targeted public health policies are needed.
[146]
The Development of Sleep Medicine: A Historical Sketch - PMC
Some of the currently classified sleep disorders, such as insomnia or nightmare, were described in early Greek, Roman, and Arabic medical treatises (Hippocrates ...
[147]
[PDF] Connections Between Sleep and Medicine in Ancient Greece ...
Hippocrates came the closest to what one would describe as modern medicine by examining the sleep patterns or circadian rhythm of his patients, but he still.
[148]
The Insomnias: Historical Evolution | Neupsy Key
Mar 18, 2017 · Hippocrates (400 BC) mentioned about sleep and sleep-related issues in his writings (Corpus Hippocraticum) [ 8 ]. In the Egyptian civilization, ...
[149]
Insomnia Disorders: Nosology and Classification Past, Present, and ...
May 14, 2021 · Three major classification systems for insomnia are the International Classification of Sleep Disorders, the International Classification of Diseases, and DSM.
[150]
The history of barbiturates a century after their clinical introduction
The present work offers an analysis of the historical development of the discovery and use of barbiturates in the field of psychiatry and neurology
[151]
The history of barbiturates a century after their clinical introduction
Nov 25, 2022 · It could calm manic patients and help melancholic patients to sleep, and was an effective inducer of sleep in insomniacs. The first trials with ...
[152]
Who discovered REM sleep? - Oxford Academic
Sep 4, 2023 · In 1950 Eugene Aserinsky began graduate work at the University of Chicago, reluctantly selecting as his mentor Nathaniel Kleitman, the pre- ...<|separator|>
[153]
History of the Development of Sleep Medicine in the United States
In 1937 Loomis in the US first documented the characteristic electroencephalogram (EEG) patterns of what is now called NREM sleep: vertex waves, sleep spindles, ...
[154]
Insomnia CBT: Assess Patient, Standard Care
This review will cover the initial assessment of insomnia, including insomnia mimics, the selection of patients for treatment and the key components of CBT ...
[155]
Insomnia nosology: a systematic review and critical appraisal of ...
Apr 30, 2023 · The DSM-III-R (APA, 1987) and the ICSD (American Sleep Disorders Association [ASDA], 1990) provided initial criteria for diagnosing insomnia ...
[156]
Discovery and development of orexin receptor antagonists as ...
... medications for insomnia. Linked ArticlesThis article is part of a themed ... Drug Discovery for Psychiatric Disorders. London: The Royal Society of ...
[157]
(PDF) Cinematic Insomnia - Academia.edu
Insomnia in Hollywood narratives is depicted as both a symptom of modernity's relentless production pressures and a mechanism for survival. The interplay ...
[158]
Sleep and Dreams as Reflected by Science Fiction Literature and ...
Aug 21, 2025 · Sleep and dreams are frequent themes in science fiction (Sci-Fi) literature and films, often used to explore questions about consciousness, ...
[159]
Whats insomnia like for most people youd never know from movies
Oct 11, 2023 · Most movies tend to either minimise or exaggerate symptoms. Insomnia is rarely depicted as a treatable illness.
[160]
Americans With Trouble Sleeping Report Their Sleep Affects Their ...
Feb 10, 2023 · ... sleep, 45% reported a reluctance to seek medication treatment, and 30% a hesitance in talking about sleep with their clinician because of stigma ...Missing: under- | Show results with:under-
[161]
Undiagnosed and untreated sleep disorders: Barriers to care
Dec 18, 2023 · These biases are often rooted in stigma and discrimination, which can exacerbate sleep disparities. Supported by egregious historical events ...
[162]
Sleep Awareness Week 2025 - National Sleep Foundation
March 8-14, 2026. Every year, the National Sleep Foundation takes this time to reemphasize the important connection between your sleep and your health and well ...
[163]
https://pubmed.ncbi.nlm.nih.gov/40836680/
[164]
Employee Sleep and Workplace Health Promotion - NIH
Half of the studies found workplace-based health promotion program exposure was associated with a desired increase in mean nightly sleep duration (n=10, 50.0%).
[165]
Employers' Dream of Controlling Health Costs Turns to Workers' Sleep
About 1 in 4 large employers offer programs to help workers get better sleep and more than half plan to implement such efforts by 2021, according to a 2019 ...
[166]
Cultural and individual factors influence sleep quantity and quality
Jul 18, 2023 · Those in collectivist culture, compared to individualist culture, also showed more records of delayed bedtime. Among the studied countries ...
[167]
Impact of insomnia: Cultural and societal aspects from a European ...
Mar 15, 2025 · The survey highlights cultural differences in insomnia perception and management in Europe. Insomnia is often trivialized, thus delaying ...