“I slept terribly last night. I think I have insomnia.”
Well, if it was just one bad night in a month, it’s unlikely to be insomnia, experts in sleep medicine say, even though the “one bad night” complaint is fairly common.
“Insomnia is a global problem and the United States is pretty similar to the rest of the world,” says Jennifer Martin, PhD, a clinical psychologist and professor of medicine at the David Geffen School of Medicine at the University of California at Los Angeles.
“About 10% of men and maybe 15% to 20% of adult women have insomnia disorder,” says Dr. Martin, who also serves on the board of directors for the American Academy of Sleep Medicine. “It’s pretty common and we don’t know if that is going to go up after Covid-19, but we do see higher rates of insomnia after other major disasters or events.”
But, she says, “A bad night of sleep now and then is not a clinical disorder. It is actually a pretty normal response to stress. A lot of people when they are stressed out, their sleep is messed up. What happens for some people is that even if their sleep gets off track because of a big life event, the sleep problem sort of takes on a life of its own, and it persists for a long period of time, maybe even after what originally got them upset is far in the past.”
“Real” insomnia
“About 7% to 10% of people would meet the diagnostic criteria for insomnia; about 30% of people exhibit insomnia symptoms,” says Russell Rosenberg, PhD, chief science officer and chief executive officer of NeuroTrials Research of Atlanta.
“Women have more insomnia that men, almost 1.5 times that of men,” Dr. Rosenberg says. “Women are more vulnerable to insomnia. The reasons for that are not very well understood. There are hormonal differences in women. We know that there are two risk factors for insomnia: Aging and gender. As we grow older, we get more physical and mental disorders that might impact sleep. Older adults do tend to sleep less at night, but they do nap more. So, their total sleep times doesn’t seem to change much as they age.”
“Chronic insomnia disorder,” says Dr. Martin, “is trouble either falling asleep or staying asleep — it can be either — that goes on for at least 3 months and happens at least 3 times a week, and then we also have this criterion that it has to be severe enough to affect how the person feels or functions during the day.
“There are some people who can sleep 6 ½ to 7 hours and they wake up and they feel fine, it doesn’t bother them, and everything is okay,” she says. “That isn’t insomnia, that’s just a naturally shorter sleep requirement. But there are some people with insomnia who sleep 7 ½ hours but they toss and turn and really only get 6 ½ hours of sleep and then they feel really tired.”
The criteria for a diagnosis of insomnia requires that a person has self-reported difficulty falling asleep and then has difficulty falling back to sleep if they wake up in the middle of the night, says Tom Roth, PhD, Director of the Sleep Disorders and Research Center at Henry Ford Hospital and professor of psychiatry at Wayne State University, School of Medicine, in Detroit.
“People have transient difficulty – there could be a death in the family, jet lag – but they don’t meet the diagnostic criteria for insomnia,” Dr. Roth says, who is also a clinical professor of psychiatry at the University of Michigan College of Medicine in Ann Arbor.
Or Sleep Deprived?
“Equally important, if not even a greater issue in this country, is voluntary sleep loss and daytime sleepiness,” he says. “We as a society don’t get enough sleep. Anyone who sleeps longer on weekends than on weekdays is sleep deprived. Getting enough sleep is not a huge problem, but it takes effort to get enough sleep. People should spend 8 hours in bed. Adolescents actually need a little bit more sleep and then it goes down. An adolescent needs 9 hours.”
“The definition of insomnia is a little loose,” says Steven Feinsilver, MD, director of the Center for Sleep Medicine at Lenox Hill Hospital, and professor of medicine at Hofstra Northwell School of Medicine in New York City.
“Insomnia is the complaint of difficulty in falling asleep, difficulty staying asleep or just a perception of bad sleep,” he says. “People’s perception of sleep is pretty poor. Most bad sleepers underestimate their sleep. We have seen that in our sleep lab for some years.
“In the sleep lab we asked everybody how they slept last night,” Dr. Feinsilver says. “I know exactly how they slept, and some people get it unbelievably wrong. I have the argument with patients who say, ‘I told you I wasn’t going to sleep,’ and I tell them, ‘Well, you did sleep.’ It might not have been great sleep, but there was some.
“Part of that is because we all remember the time we were awake,” he says. “We don’t remember the time we were asleep. So, your perception that you have been awake all night is often not accurate. The perception of non-restorative sleep or poor sleep is even more difficult to figure out. It is a little different from daytime sleepiness.
“Daytime sleepiness is not common with insomnia, which is really interesting,” he says. “Most people who say they sleep like 3 hours a night but when I ask if they have trouble staying awake during the day, they usually don’t. The thinking is that either bad sleepers underestimate their sleep, or they have difficulty turning their brain off: If they are not very good at doing it at night, they won’t be good at doing it during the day either.
“People who are truly sleepy during the day are more likely to have sleep deprivation as the result of not sleeping enough or they have a disease like sleep apnea,” Dr. Feinsilver says. “If you are not getting enough sleep, sleep apnea is the most common reason to be sleepy. But that is different from insomnia.”
Despite being a common problem, the vast majority of people who have insomnia or who believe they have insomnia do not seek treatment for insomnia.
“I live in California and I have had patients who had sleep disturbances after an earthquake, and that went on for a long time before they sought help,” says Dr. Martin. “And of those, only a very small minority of these people actually seek professional help. Insomnia is one of those conditions that people don’t often think to talk to their clinicians about either, because they don’t think it is important and they are trying a lot of things by themselves.”
Next: A New Sleeping Pill
Source: Various telephone interviews.
Disclosure: Dr. Roth disclosed that he consults for many companies who do work in insomnia, including Merck, Eisai, Novartis. Rosenberg disclosed that he and his research organization consult for all the companies that work on insomnia issues. Dr. Martin and Dr. Feinsilver disclosed no relevant relationships with industry.
