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Sleepless? We've been there and can help

No sleep or very little sleep

A lack of sleep is often referred to as insomnia, but very specific medical criteria need to be met to be diagnosed with insomnia. It is important not to self-diagnose. But rather, to review the information with a trained medical provider or specialist.

Insomnia symptoms

Insomnia Disorder, a type of sleep-wake disorder
Insomnia is characterized by a predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:

 

1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.

Further, the additional criteria below must be met:

  • The sleep difficulty is present for at least 3 months.

  • The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.

  • The sleep difficulty occurs at least 3 nights per week.

  • The sleep difficulty occurs despite adequate opportunity for sleep.

  • The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

  • Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

  • The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

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The following specifiers can be used by the diagnosing practitioner to further identify the causes of your insomnia:

  • Non-sleep disorder mental comorbidity, including substance use disorders.

  • With other medical comorbidity (this just means another medical diagnosis that may be causing your sleep issues).

  • With other sleep disorder (this is used if another sleep disorder is also present).

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Duration specifiers:

Episodic: Symptoms last at least 1 month but less than 3 months.
Persistent: Symptoms last 3 months or longer.
Recurrent: Two (or more) episodes within the space of 1 year.

Note: Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but otherwise meeting all criteria with regard to frequency, intensity, distress, and/or impairment) should be coded as another specified insomnia disorder
 

Citation:

United States Substance Abuse and Mental Health Services Administration (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health.

Insomnia causes

​Here are a few key causes of insomnia:

  • Depression

  • Anxiety

  • General physical health problems

  • Obstructive sleep apnea

  • Substance Use

  • Behavioral Factors

    • Taking naps​

    • Excessive time in bed

    • Using the bed for work

    • Screentime in bed (associates the bed with wakefulness)

    • Drinking caffeine or exercising close to bedtime

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Citations:

Arroll, B., Fernando, A., Falloon, K., Goodyear-Smith, F., Samaranayake, C., & Warman, G. (2012). Prevalence of causes of insomnia in primary care: a cross-sectional study. British Journal of General Practice, 62(595), e99-e103.

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Stepanski, E. J. (2006). Sleep: A Comprehensive Handbook, Chapter 13: Causes of Insomnia. Edited by Teofilo L. Lee-Chiong. pp. 99-102.

Questions to assess insomnia causes for adults:

  • Am I maintaining a regular daily sleep schedule? If not, the inconsistency may be disrupting circadian rhythms.

  • Am I avoiding naps? Napping can result in a lack of night time sleepiness, so try to avoid naps at all costs.

  • Am I exercising early enough in the day? Exercising too late can produce endorphins that promote wakefulness.

  • Am I consuming alcohol, caffeine, nicotine or other substances in the hours before bedtime?

    • Alcohol: should be avoided within 2-3 hours of bedtime​

    • Caffeine: should be avoided within 4-6 hours of bedtime

    • Nicotine: should be avoided at least 1 hour prior to sleep

  • Am I checking the clock excessively when I have trouble falling asleep or staying asleep? Avoid doing so, as it only promotes anxiety. If you cannot sleep after 20 minutes, get up and do a relaxing activity, such as reading.​

  • Am I avoiding screen usage at night and in the bedroom? The blue light released by screens can promote wakefulness. If you must use a screen, utilize the phase shifting feature present in many phones that allows the blue light to be filtered.

Insomnia solutions and sleep tips for your child:

1.    Provide a comfortable sleep environment

  • The child should have their own space to sleep (bed or shared bed with sibling).

  • Make sure the room is comfortably cool, quiet and dark

2.    Establish a consistent bedtime routine

  • The routine should be short, predictable and consistent

  • Try to include some calming activities 

  • Some children may find bathing stimulating rather than relaxing, so this may not be a part of a calming bedtime routine

  • Children may benefit from the use of a timer during the bedtime routine

3.    Maintain a regular schedule

  • Sleep and wake times should be consistent, 7 days per week

  • Delay bedtime (temporarily) if it takes more than one hour for your child to fall asleep

  • If child is still napping, keep a regular schedule and wake by 4 p.m.

  • Maintain a regular meal schedule and daytime light/nighttime darkness (in the summer dark blackout shades may be useful at bedtime)

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4.    Teach your child to fall asleep alone
Strategies for Sleep Resistance and Night Wakings

  • Traditional “crying it out” may not be best approach

  • “Checking in”

    • Let your child to try to fall asleep on his/her own and leave room

    • Go back into your child’s room if he/she is upset

    • Comfort but keep interactions “brief and boring”

    • Extend the length of time between visits

  • The Rocking Chair Method

    • Let your child fall asleep on his/her own but stay in room in rocking chair with your back to your child

    • Move the chair closer to the door each night until you are out of the door

  • Use rewards! Morning stickers or a ‘treasure box’ of small toys to choose from

5.    Avoiding Naps

  • Once a child has outgrown daytime naps it is best to avoid daytime naps (except in special circumstances like illness)

6.    Consider daytime activities that promote a better sleep/wake schedule

  • Sleep Activities

    • Exercise during the day promotes nighttime sleepiness

    • Avoid stimulating activities or exercise 2-3 hours prior to bedtime

    • Avoid TV, videogames or computer time 2-3 hours prior to bedtime

  • Caffeinated food and beverages

    • ​Eliminate completely or avoid several hours before bedtime

    • The effect of caffeine can last 3-5 hours and in some kids, up to 12 hours

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