Insomnia and sleep disorders: causes, treatments and cognitive therapy

01Understanding the different types of insomnia#

Insomnia is a sleep disorder characterised by difficulty falling asleep, prolonged nocturnal awakenings, early awakening without return to sleep or poor sleep quality with a feeling of non-recovery. To medically speak of insomnia, these difficulties must occur at least three times a week for at least three consecutive months, with objectifiable daytime impact (fatigue, decreased performance, irritability, cognitive disorders). Below this definition, we speak of occasional sleep disorders that do not require specialised management.

Insomnia affects approximately 30% of adults worldwide according to WHO data, making it one of the most frequent disorders in general practice. In Morocco, the figures converge: according to Moroccan Society of Sleep Medicine data, nearly one in four people consults at least once for sleep disorders, and approximately 10% of the adult population suffers from characterised chronic insomnia. Women are more affected than men (about 1.5 times), and prevalence increases with age, particularly after 60 where more than 40% of subjects complain of sleep disorders. Modern lifestyles — screen exposure, teleworking, shifted schedules, professional anxiety, mental load — contribute to a worrying increase in sleep disorders in young adults.

Three major forms of insomnia are classically distinguished according to duration and context. Occasional insomnia, lasting less than a week, is generally linked to a punctual event (acute stress, travel, new environment) and resolves spontaneously with the disappearance of the triggering factor. Acute insomnia, lasting from 1 week to 3 months, is typically linked to an identifiable stress factor (bereavement, conflict, professional problem, illness) and requires structured management to avoid the transition to chronicity. Chronic insomnia, lasting more than 3 months, concerns approximately 10% of the adult population and requires a multidisciplinary therapeutic approach because the factors maintaining it have become partially independent of the factors that triggered it.

02The main causes of insomnia#

Insomnia is rarely monocausal — it generally results from the convergence of several psychological, behavioural, medical and sometimes drug factors. Identifying these factors is essential to adapt management.

Psychological causes largely dominate, representing approximately 60% of chronic insomnias. Generalised anxiety, with its incessant nocturnal ruminations ("what if...", "I must not forget..."), is probably the leading cause of falling-asleep insomnia in young and middle-aged adults. Depression classically manifests as early awakening (between 3 AM and 5 AM) with inability to fall back asleep and morning sadness. Chronic professional stress or family stress maintain a state of hyper-arousal incompatible with sleep. Old psychological traumas (unresolved bereavements, abuse, violence) can cause persistent sleep disorders long after the initial event. Several recent Moroccan studies document an increase in anxious insomnia since the Covid-19 pandemic and associated economic crisis.

Lifestyle factors are often underestimated but fundamental. Late caffeine consumption (coffee, tea, sodas, energy drinks after 2-3 PM) disrupts falling asleep in sensitive subjects — caffeine half-life is 5 to 6 hours, sometimes longer in slow metabolisers. Alcohol in the evening, contrary to a popular idea, favours falling asleep but considerably fragments sleep in its second half. Screens before bed (smartphone, tablet, television, computer) emit blue light that inhibits melatonin secretion and delays sleep onset by 30 to 60 minutes on average. Irregular schedules (variable bedtimes and wake times, especially on weekends), shift or night work, jet lag in frequent travellers, desynchronise the biological clock. Daytime nap that is too long (more than 30 minutes or after 4 PM) compromises night-time sleep onset by reducing homeostatic sleep pressure.

Several medical causes deserve to be systematically sought as their specific treatment resolves insomnia. Chronic pain (low back pain, osteoarthritis, fibromyalgia, neuropathic pain) obviously disrupts sleep. Nocturnal gastro-oesophageal reflux causes pyrosis and cough that wake the patient. Obstructive sleep apnoea syndrome, particularly frequent in overweight, snoring and hypertensive subjects, is one of the most underdiagnosed causes of insomnia and daytime fatigue — it must be systematically considered and screened by polysomnography. Restless legs syndrome (irresistible urge to move legs, relieved by movement, predominating in the evening) is a frequent neurological disorder. Menopause in women is classically accompanied by nocturnal vasomotor flushes responsible for insomnia. Hyperthyroidism, certain neurological pathologies (early Parkinson, dementia) can also disrupt sleep.

Several medications can cause or aggravate insomnia: systemic corticosteroids (to be taken in the morning to limit the effect), beta-blockers in sensitive patients, vasoconstrictor nasal decongestants (pseudoephedrine), stimulating antidepressants (fluoxetine, venlafaxine — to be taken in the morning), some antihypertensives, stimulants like modafinil or methylphenidate, toxic substances like cocaine or amphetamines.

03Health consequences#

Chronic insomnia is not just a daily inconvenience — it constitutes a real medical risk factor whose cumulative consequences can be considerable in the long term. Recent epidemiological studies have made it possible to quantify these risks precisely.

On the cardiovascular level, chronic insomnia increases the risk of stroke by approximately 28% according to a meta-analysis published in Neurology in 2019. The risk of arterial hypertension is increased by 40%, through chronic activation of the sympathetic nervous system and disruption of nocturnal blood pressure regulation mechanisms. The risk of myocardial infarction is also significantly increased.

On the metabolic level, the risk of type 2 diabetes is increased by approximately 17%, through disruption of satiety-regulating hormones (leptin, ghrelin) and insulin sensitivity. Chronic sleep deprivation favours weight gain and obesity, partly through hormonal imbalance and partly through increased compensatory eating behaviours (nocturnal snacking).

On the psychiatric level, the risk of depression is increased by approximately 45%, creating a particularly difficult vicious circle: insomnia favours depression, which itself worsens insomnia. The risk of anxiety disorder and impulse control disorder is also increased.

On the functional and accident level, the risk of road accidents is multiplied by 2.5 in chronic insomniacs, making it a public health issue beyond the individual. Professional performance is impaired (concentration, memory, decision making), irritability increases, interpersonal relationships deteriorate. The immune system is weakened with increased risk of infections, slowed wound healing, and weaker vaccine response.

All these elements justify taking chronic insomnia seriously and not resigning oneself to the idea that "that's how it is". Adapted management is effective in the vast majority of cases.

04When to consult for insomnia#

Several situations require consulting without delay to obtain structured medical advice. Insomnia persisting more than 3 weeks without spontaneous improvement justifies a consultation with the treating doctor to assess possible causes and adapt management. Nocturnal awakenings with sensation of choking or suffocation are very evocative of sleep apnoea syndrome and should lead to polysomnography. Disabling daytime sleepiness that disrupts work, driving or daily activities should never be trivialised. Restless legs symptoms (irresistible urge to move legs in the evening, tingling, pins-and-needles, relief by movement) deserve specialist advice. Depression or dark thoughts associated with insomnia are psychiatric emergencies. Snoring with respiratory pauses reported by the bed partner, particularly in overweight or hypertensive subjects, should suggest sleep apnoea.

The polysomnographic recording, performed at a sleep centre, is the reference examination for diagnosing sleep apnoea syndrome or other complex sleep disorders. It involves spending a night in a hospital service or specialised clinic, equipped with sensors that record EEG (cerebral activity), EMG (muscular activity), ECG, breathing, oximetry, eye movements. In Morocco, polysomnography is available in several centres: CHU Ibn Sina in Rabat, CHU Ibn Rochd in Casablanca, CHU Hassan II in Fes, several private clinics in major cities. Cost varies from 2,500 to 4,500 MAD depending on facilities, partially reimbursed by AMO on specialist medical prescription. A simplified alternative is home ventilatory polygraphy, sufficient for screening simple sleep apnoeas.

05CBT-I: the reference treatment#

Cognitive Behavioural Therapy for Insomnia (CBT-I) is now considered by French HAS, the American NIH, and all sleep medicine learned societies as the first-line treatment for chronic insomnia. It is more effective than sleeping pills in the long term and does not expose to side effects or drug dependence. Several comparative studies have shown that 70% of CBT-I patients benefit from lasting improvement at 1 year, compared to only 30-40% with medication alone.

CBT-I is a structured psychotherapy, generally in 6 to 8 weekly sessions of 45 minutes, followed by progressive spacing. It can be conducted by a psychiatrist, a trained psychologist, or a sleep medicine doctor. In Morocco, several practitioners in Casablanca, Rabat, Marrakech and other major cities offer this approach. Cost of a session is between 400 and 700 MAD in the private sector, partially reimbursed by some complementary mutuelles (outpatient psychotherapy remains insufficiently covered by basic AMO, which is one of the limits of the current system).

Five main components structure CBT-I. Sleep restriction is paradoxically the most effective element: it consists of staying in bed only the actual estimated sleep time (for example, if you actually sleep 5 hours per night, only spend 5 hours in bed), which increases homeostatic sleep pressure and improves consolidation. Stimulus control aims to recondition the bed-sleep association: only go to bed when really sleepy, leave bed after 15-20 minutes of wakefulness to go to another room and do something calm until the urge to sleep returns, do not use the bed for anything other than sleeping and having sexual relations. Relaxation techniques (cardiac coherence, 4-7-8 breathing, Jacobson's progressive muscle relaxation, mindfulness meditation) reduce hyperactivation incompatible with falling asleep. Cognitive restructuring helps identify and modify dysfunctional beliefs that maintain insomnia ("I absolutely must sleep 8 hours", "I won't be able to function tomorrow if I sleep poorly", "my insomnia will make me ill"). Sleep education provides basic knowledge on circadian rhythms, sleep cycles, drug effects, which help better manage the disease daily.

06The ten rules of sleep hygiene#

Beyond CBT-I, several sleep hygiene rules are validated by studies and applicable by all, whether or not in chronic insomnia.

The first rule is regularity of schedules. Going to bed and getting up at fixed hours, even on weekends (with maximum 1-hour tolerance), synchronises the biological clock and considerably improves sleep quality. Weekend "lie-ins" can paradoxically aggravate weekday insomnia. The bedroom must be cool (ideal temperature between 17 and 19°C), completely dark (blackout curtains, eye mask if needed) and silent (earplugs if the environment is noisy). These environmental conditions have considerable and often underestimated impact on sleep quality.

Do not consume caffeine after 2 PM (coffee, black tea, green tea, sodas, dark chocolate) is a simple but often neglected measure — caffeine's 5- to 6-hour half-life means that a coffee at 4 PM still leaves half the active caffeine at 10 PM. Avoid alcohol in the evening at least 3 hours before bedtime: it falsely favours falling asleep but fragments sleep in its second half and reduces REM sleep. No screens in the hour preceding bedtime: blue light inhibits melatonin and delays falling asleep. If use is unavoidable, activate blue light filters or wear blue-light-blocking glasses.

Eat a light meal 3 hours before bedtime: a too copious, fatty or spicy dinner disturbs sleep through difficult digestion and reflux. Practise regular daytime physical activity (at least 30 minutes), ideally in the morning or early afternoon, but not in the 3 hours preceding bedtime as activity raises body temperature and sympathetic arousal. Expose yourself to natural light in the morning (15-30 minutes ideally) consolidates the circadian rhythm and improves evening melatonin secretion. If a nap is necessary, limit it to 20-30 minutes maximum and take it before 3 PM so as not to compromise night sleep.

07Sleeping pills: to use with caution#

Sleeping pills have their place in insomnia management, but their use must be strictly limited due to risks linked to prolonged use. Several classes exist with different profiles.

Benzodiazepines (diazepam/Valium, lorazepam/Témesta, oxazepam/Seresta, alprazolam/Xanax) are effective in the short term for inducing sleep but present several major drawbacks in prolonged use: development of tolerance in 2 to 4 weeks (loss of efficacy), physical and psychological dependence, rebound insomnia on withdrawal, memory and concentration disorders, fall risk in elderly people (with hip fractures), increased road accidents, possible long-term cognitive deleterious effects. HAS recommends a maximum duration of 4 weeks, reserving these molecules for acute situations (bereavement, serious event) with progressive withdrawal.

Drugs related to benzodiazepines (Z-drugs) like zolpidem (Stilnox) and zopiclone (Imovane) are pharmacological cousins with a slightly different profile (less rebound) but globally similar risks. Same recommendations of duration limited to 4 weeks.

Extended-release melatonin (Circadin) is particularly interesting in patients over 55 whose endogenous melatonin production physiologically decreases with age. It does not cause dependence, presents very few side effects, and improves sleep quality without modifying its structure. In Morocco, its reimbursement is variable depending on funds. It is also useful in the context of jet lag.

Sedative antidepressants like trazodone (Donaren) or low-dose mirtazapine (Norset) can be useful if depression is associated with insomnia, or sometimes off-label use for stubborn insomnia. Their long-term tolerability profile is better than benzodiazepines.

Sedative antihistamines (doxylamine/Donormyl, diphenhydramine) are over-the-counter in some pharmacies but should not be used long-term due to anticholinergic effects worrying in the elderly (confusion, constipation, urinary retention, cognitive disorders).

The golden rule to remember: sleeping pills treat the symptom, not the cause. They can serve occasionally, but the basic treatment of chronic insomnia remains CBT-I, which is more effective, durable and safer. If you have been taking a sleeping pill for more than 3 months, it's time to talk to your doctor about organising progressive reduction and exploring non-medication alternatives.