• Insomnia is a very widespread sleep disorder: around 13 million people in Italy suffer from it.
• Stress, worries, genetic predisposition and poor sleep habits all contribute to the onset of chronic insomnia.
• The scientific community places cognitive behavioural therapy at the forefront of treatment for this condition.

Insomnia is far more than a nocturnal nuisance. In its most severe cases — those that persist over time — it is right to speak of a medical condition. Around 6–7 million Italians suffer from it, a figure that doubles to 13.4 million when transient insomnia is added to the chronic form, according to the latest data from Aims — the Associazione italiana medicina del sonno, which has been promoting research, outreach and clinical training on sleep for more than thirty years. And yet 46 per cent of Italians with insomnia do nothing to address the problem. Why?

Chronic insomnia is a disease

"Many people do not consider the range of consequences they face to be serious enough to warrant entering a treatment and recovery process — that is, to tackle the problem," explains Luigi De Gennaro, full professor in the Department of Psychology at the Sapienza University of Rome and Secretary of the Associazione italiana di medicina del sonno.

"The other reason is that insomnia very often presents alongside other problems, predominantly anxiety and depressive disorders, which independently carry a similar status. On one hand, there is the social stigma attached to talking about them; on the other, there is the assumption that they are not health problems on a par with others we do take seriously. In practice, that is simply not the case. Chronic insomnia is, to all intents and purposes, a disease."

Types of insomnia: acute and chronic

The four most common types of insomnia — difficulty falling asleep (initial/early insomnia), frequent and prolonged night-time awakenings (maintenance insomnia), early morning waking (late insomnia) and, finally, a combination of the foregoing (mixed or generalised insomnia) — have an immediate impact on daytime quality of life and, in their chronic form, can deplete a person's overall state of health.

When does insomnia become serious? There is no single answer, but it is essential to draw a distinction: "Acute insomnia is short-term. Whereas insomnia is conventionally considered chronic when its symptoms have persisted for more than three months in the person's clinical history: it is estimated that around 6–7 million people in Italy suffer from it," De Gennaro clarifies. It is natural to ask where this widespread malaise originates.

Why do we sleep badly? The causes of insomnia

For Alain de Botton, there is no need to look far. In a video entitled "Ecco perché dormiamo male", the writer, philosopher and television presenter points the finger at the mirror. Insomnia, he argues, is the "revenge" of our own minds for all the troublesome thoughts we have brushed aside during the day.

Sleep coach and insomnia therapist Camilla Stoddart takes a similar approach, and in the pages of the Guardian she relieves us of all responsibility: if falling asleep is a passive process, much like breathing and digesting, then there is little point in straining to sleep. It is better to work with an expert on the underlying causes — namely, a lack of sleep drive and hyperarousal, in plain terms an overload of the sympathetic nervous system that leaves us anxious and stressed.

Of course, the events of recent years have done little to help us relax, beginning with the Covid-19 pandemic, which left us with an extra dose of dark circles under our eyes (the New York Times called it "coronasomnia"), continuing with the war in Ukraine, extreme heat that has robbed us of an average of 44 hours of sleep per year, and the eco-anxiety that gallops in response to news of wildfires, floods and other natural disasters caused by the climate crisis.

Insomnia puts a great strain on the nervous system, more so than work or even amusement.

Sir Arthur Conan Doyle

To be clear, it is worth knowing that there are three categories of causes underlying insomnia, known as the three Ps: predisposing factors, precipitating factors, perpetuating factors. Professor De Gennaro explains them: "The first are stable characteristics of the individual that confer the theoretical risk of developing an insomnia disorder: these are genetic factors and, sometimes, personality factors. The second essentially coincide with life itself: they are stress-related factors, bereavements, but also positive emotions. As for the last — the perpetuating factors — these identify the conducts and behaviours that people adopt in the belief or expectation of coping with insomnia, paradoxically contributing to stabilising and reinforcing the disorder." An example? An afternoon nap lasting more than twenty minutes, or spending more time lying awake in bed, waiting in vain for the embrace of Morpheus.

Women and the elderly most affected

Despite their broadly "democratic" nature, given the figures cited above, sleep disorders strike two categories of individuals with particular frequency and intensity: women and the elderly. "The ratio ranges from 1.4 up to, in some cases, twice as many females developing insomnia compared with males," De Gennaro notes. "A very striking figure, but not an isolated one, if one considers that the two afflictions of the century have exactly the same status: anxiety and depression also often show a prevalence that is almost double in females compared with males." To date, the reasons remain unclear. "In women there are at least two unique life transitions, not shared by men: one is pregnancy and the other is the menopause, both of which are phases associated with insomnia. But they do not explain the figures mentioned above."

As for the elderly, it is well established that as age advances, even in the absence of other conditions, our sleep deteriorates in both quantity and, above all, quality: awakenings become more frequent, sleep becomes more fragmented, and the deepest stage of sleep is physiologically lost.

Insomnia during pregnancy

"Since becoming pregnant, I haven't slept." A fairly common statement among expectant mothers, which captures a range of symptoms attributable to the same sleep disorder.

Without generalising, and bearing in mind that the intensity and timing vary, insomnia during pregnancy is estimated to occur in the first trimester with an incidence of 13 per cent, in the second trimester with an incidence of 19 per cent, and in the third trimester at 66 per cent. A crescendo that goes hand in hand with the amplification of physical, hormonal and psychological change in the expectant mother.

Nausea, swollen legs, back pain, frequent urination and difficulty finding a comfortable position are among the most common causes of poor-quality rest during this delicate phase of a woman's life. Increased levels of oestrogen and progesterone also have effects on sleep and breathing.

Finally, anxiety and worry can sometimes play a significant role in exacerbating the symptoms of insomnia in the expectant mother.

Remedies include the use of pillows or other measures to find the most comfortable sleeping position, avoiding heavy or large evening meals, and practising relaxation and breathing techniques drawn from disciplines such as yoga. In any case, especially when insomnia becomes persistent, it is always advisable to consult one's gynaecologist.

The health consequences

While for Jack Kerouac, who wrote beside his bed "from midnight to dawn, with something to drink to sustain the weariness," and some of his illustrious colleagues, the consequences of sleepless nights are expressed in timeless literary masterpieces, ordinary mortals must contend with far less poetic outcomes.

"The short-term ones are deficits in attention, performance and quality of daily life for the insomniac. They are difficult to quantify but we see them consistently in studies, across all age groups." As for medium- to long-term consequences, chronic poor sleep can weaken the immune system, reduce memory and concentration, and increase the likelihood of chronic conditions such as depression, type 2 diabetes and heart disease.

However, De Gennaro cautions against alarmism: "On the one hand there are numerous studies demonstrating that insomnia acts as a risk factor for cardiovascular disease, Alzheimer's and other pathological conditions. One must always bear in mind that these are risk studies — meaning that a study has shown there is a probability that the patient may develop these conditions after a number of years, but I would obviously never venture to suggest a direct cause-and-effect relationship between these conditions and insomnia. Nevertheless, it is appropriate for people to factor in this possibility in their preventive health behaviour." The good news is that solutions are available.

What are the remedies for insomnia?

Sweet dreams with cognitive behavioural therapy

Between counting sheep and watching actor Matthew McConaughey contemplating the rain (the video lasts an hour, on the soporific streaming platform Napflix), the choice is subjective and the effectiveness debatable.

Although no guidelines exist for the treatment of insomnia, "In the chronic form, the first-line treatment recommended by international scientific societies is cognitive behavioural therapy," states De Gennaro. Paradoxical? Not at all, given that the vast majority of medications should not be used for more than four weeks, against the minimum three-month duration of chronic insomnia. "Moreover, there is a perceived immediacy in pharmacological efficacy compared to psychotherapeutic treatments, which require at least seven to eight weeks — without taking into account that this approach addresses the aetiological factors, that is, the underlying causes of the problem, whereas pharmacological ones do not at all, and often trigger a mechanism of dependency and tolerance." In cases of chronic sleep disorders, it is essential to consult a specialist and embark on a process of changing behaviours, beliefs and habits.

The protocol is generally organised into eight modules, each involving specific techniques and objectives. The main ones are aimed at reinforcing the bedroom-bed-sleep association and removing the factors that condition the mind not to sleep; at increasing sleep efficiency by temporarily reducing the time spent in bed, based on the principle of sleep homeostasis, according to which reducing hours of sleep increases the likelihood of falling asleep; and at guiding the patient in managing moments of reflection on their problems and worries, outside the bedroom.

When to take medication and for how long at most

"Acute insomnia is the only form for which medical and scientific societies recommend medication as the first therapeutic approach," notes De Gennaro. These are predominantly products based on benzodiazepines which, however, offer immediate relief without eradicating the problem at its root, increase the risk of habituation and therefore the need for increasing dosages, in most cases should not be used beyond four weeks and can leave a feeling of grogginess in the morning.

If the insomnia problem has arisen recently, and always under medical supervision, it is possible to consider the broad spectrum of natural remedies.

Natural remedies

Dr Stefania Piloni, lecturer in phytotherapy at the University of Milan, advises: "The idea is to start the day in great shape from the morning and gradually encourage relaxation as evening approaches. On waking, one can take rhodiola, a plant that the Vikings also used to keep their energy levels high; or maca, a Peruvian plant that promotes morning vitality. In the evening, on the other hand, for those who struggle to fall asleep there is hawthorn, which regulates the heart rhythm when there is a little too much anxiety and has a mild anxiolytic effect; valerian and passionflower for those who fall asleep and wake up fitfully: it is important to take them together, because they work synergistically; for those who wake up in the night but always at the same time, melatonin works well: here we are not in the plant world but it is a valid support for maintaining deeper sleep; finally, for those who regularly open their eyes ahead of the alarm, Withania somnifera is recommended, an Indian plant that also helps to start the morning with extra drive."

In all these cases, a little patience is required: unlike medications, the first results of plant-based supplements appear after at least seven to ten days.

Goodnight to the smartphone

Many specialists maintain that digital devices are best kept out of the bedroom, especially for those who have difficulty falling asleep. At the same time, there is significant growth in the market for apps to combat insomnia which, according to an analysis by Global Market Insights Inc., will reach 67 billion dollars by 2030.

Some look with confidence at the possibilities offered by technology: in Scotland, for example, in 2021 the Government made a non-pharmacological treatment freely available to all national health service patients, delivered as a digital therapy through an application (Sleepio) made available free of charge. The results of the initiative are not yet known.

The medical profession's appeal to policymakers

Chronic insomnia can no longer be downgraded to a condition one simply lives with. It is a genuinely debilitating condition and, as such, requires appropriate care and support. For this reason, on 27 June last, in Rome at the Sala caduti di Nassirya of the Senate of the Republic, the Policy brief on chronic insomnia was presented — a detailed document drawn up by a number of scientific and clinical societies, designed to provide an initial information base for policymakers so that they may act in the right direction. One can only hope they won't sleep on it.