Primary insomnia is described as difficulty initiating or maintaining sleep, or experience of nonrestorative (nonrefreshing) sleep, for at least 1 month. The term primary indicates that the insomnia is not caused by any known physical or mental condition.

There are numerous causes and risk factors. Primary insomnia is the most common sleep disorder. Commonly, everyday anxiety and stress, coffee, and alcohol are the biggest culprits.

About 25% of elderly people and about 15% of the general population suffer from insomnia, but this includes both primary and secondary insomnia, which can be caused by depression and other mental and physical illnesses.

Primary insomnia is often characterized by both difficulty falling asleep and by repeated awakenings. People often feel fatigued the next day. People who suffer from this are generally preoccupied with getting enough sleep. The more they try to sleep, the greater the sense of frustration and distress and the more elusive sleep becomes.

Clinical history (including all current medication and recreational drug use) and physical exam are usually sufficient to make the diagnosis. Polysomnography, an overnight sleep study, can be helpful to rule out other types of sleep disorders (such as breathing related sleeping disorder).

Depression is a very common cause of secondary insomnia and it should be ruled out before primary insomnia is diagnosed. Often, insomnia is the symptom for which people with depression seek medical attention.

Depression includes low mood or inability to feel pleasure in usually pleasurable things for more than two weeks, sleep changes (too much, too little, interrupted sleep (especially early morning wakening with inability to fall back asleep), unrefreshing sleep), eating changes (too much or too little), a feeling of slowness or sluggishness of movement, or a feeling of agitation, irritability, anxiety, feelings of low self worth and/or suicidal thoughts.

If you have insomnia, report any of these other symptoms to your health care provider so that you can be screened for depression. Antidepressant medications often solve insomnia problems related to depression, but some can also cause sleep problems so medications may need to be adjusted if this occurs.

Nonspecific measures to induce sleep (sleep hygiene):

• Using the bed only for sleep and sex
• Going to bed at the same time every night
• No daytime napping
• No caffeine, alcohol, or nicotine
• Eliminating the conditioned anxiety that comes with trying to sleep, often by doing things like reassuring yourself that you will sleep and distraction
• Maintain comfortable sleeping conditions
• Eat at regular times daily; avoid large meals near bedtime
• Exercise early in the day
• If you are not asleep after 5-10 minutes in bed, simply get up and do something else; sometimes changing to another room is helpful; this can also help reduce anxiety about falling asleep
• Practice evening relaxation routines, such as progressive muscle relaxation or meditation

If the above recommendations are followed and the person continues to have insomnia, medications including benzodiazepines can be used. However, sleep medications should not be prescribed for more than 2 weeks because tolerance and withdrawal may occur. This can make sleeping even more difficult when the drug is stopped.

The prognosis is very good if the person sticks to the behavioral maneuvers (sleep hygiene). A doctor should evaluate chronic insomnia that does not improve.

It is important to remember that one's health is not at risk if one does not get 6 to 8 hours of sleep every day and that different people have different natural sleep requirements.

Some do fine on 4 hours a night, while others only thrive if they get 10-11 hours. Sleep requirements also change with age. Listen to your body's sleep signals and don't try to sleep more or less than is refreshing for you.

Daytime sleepiness is the most common complication, though there is some evidence that lack of sleep can also lower your immune system's ability to fight infections. Sleep deprivation is also a common cause of auto accidents -- if you are driving and feel sleepy, take a break.

Call your doctor if chronic insomnia has become a problem.