Rebound insomnia

Rebound insomnia is when you can’t sleep after coming off sleeping pills. Your brain and body have adjusted to the sleep medication and almost anticipate it. The feedback mechanisms have had their set points adjusted, to some extent. The set points change back of course, but in the short run your body experiences insomnia in response to the lack of drug. A related phenomenon is “rebound pain” that people experience when they stop taking pain relievers. Some people experience both rebound pain and rebound insomnia if they have been taking something like Tylenol PM, which contains both a pain reliever and an antihistamine.

Rebound insomnia also occurs in people taking drugs for reasons other than insomnia.  For instance, an opioid given for severe pain will affect the patient’s sleep as will a benzodiazepine given for anxiety.  When these drugs are discontinued, the patient may notice trouble sleeping through the night.

Rebound insomnia is very common, and a reason to avoid medication if possible. One way to reduce it is to wean yourself off the drug. Reduce the dosage over a few nights to permit your body to slowly get used to sleeping without the medicine. We address this in our page on sleep medicines, You can also try other methods of getting to sleep: good sleep hygiene, exercise, warm milk. Even a different type of sleeping pill would probably work, but doctors would almost certainly not recommend using one sleep aid to counteract rebound insomnia caused by stopping a different sleep aid. Consult a doctor if you feel this is the only way.

"What the will and reason are powerless to remove, sleep melts like snow in water" – Walter de la Mare – Behold, the Dreamer

Altitude insomnia

sleeping personYou sometimes hear the term “altitude insomnia” when people can’t sleep after climbing a mountain (or flying to a city like Denver.) More formally, there is a condition called Acosta’s syndrome, or hypobaropathy, or altitude sickness, which can have many symptoms, including sleeplessness. Sensitive individuals experience this when they go up as little as 2000 ft in elevation.

While in extreme cases altitude sickness can be serious, most people suffer through the discomfort and adjust in a few days. The no-brainer solution to this sickness is to descend back to the starting elevation, at which point symptoms usually clear rapidly.

Insomnia related to substance use

Substance use refers to alcohol, stimulants, drugs (both recreational and medicinal), and accidental ingestions of external items. Substances are often used together, compounding the effect and making identifying the cause of the sleeplessness difficult.  See our page on alcohol and sleep.  Both nicotine and marijuana use alter sleep patterns.

The same substance can have opposite effects on different individuals: caffeine seems to help some people fall asleep while it keeps others up. Poisons can also interrupt sleep and a symptom of low-dose poisoning is insomnia. These poisons could include spider venom and lead.

Insomnia due to substance use and abuse is a type of secondary insomnia.  Every serious insomnia treatment program will address substance use.

Adjustment Sleep Disorder

Adjustment sleep disorder refers to insomnia caused by a change in life, such as stress or environmental change. It is distinct from jet lag and shift-work sleep disorder in that there is no forced change in sleep times. The body has trouble changing to the new situation, physically or psychologically. This is often a transient insomnia if the stress disappears or the sleeper adapts.

Non-restorative sleep

Some psychologists and medical doctors have been using the phrase non-restorative sleep (abbreviated NRS), but this terminology has not been officially adopted by any formal body. It generally means the feeling at waking of not being refreshed. Plenty of people experience it, but it doesn't necessarily mean it fits the clinical definition of a sleep disorder the way difficulty initiating and maintaining sleep (insomnia) does.

Note that a person who experiences non-restorative sleep can sleep through the night, so it is not a type of insomnia, but the person will experience excessive daytime sleepiness, the major daytime symptom and downside of insomnia.

People with diseases such as chronic fatigue syndrome experience this phenomenon.  The connection between the immune system and the drive for sleep may explain why sick people always feel tired and sleepy.  It is not that they don’t get enough sleep or enough slow-wave (deep) sleep.  It’s that even with enough sleep their brain’s sleepiness meter does not reset.  People with seasonal affective disorder (SAD) are in the same boat.


Some Canadian researchers have proposed a non-restorative sleep scale (NRSS) to quantify the subjective severity of lack of refreshment after apparently normal sleep. People with mental illness often complain of non-restorative sleep as do those with fibromyalgia and chronic fatigue syndrome. While these people often have daytime sleepiness too, the feeling of insufficiently refreshing sleep is common enough that doctors and psychologists are starting to consider non-restorative sleep as a separate symptom.

It remains to be seen whether the proposed 10-question Canadian scale catches on with diagnosticians, or if another such scale becomes a diagnostic standard.

Paradoxical Insomnia

This type of insomnia is called paradoxical because it is not really insomnia in an objective sense, at least to an external observer.  People who complain about not being able to sleep but whose EEG readings show they are sleeping normally are said to have paradoxical insomnia.  A more formal name is Sleep State Misperception.  (A less charitable name is sleep hypochondriasis).  Sufferers are convinced they failed to sleep through much of the night.  They usually do not have daytime sleepiness a person who failed to sleep through the night would have.  When asked to estimate how much of the night they spent asleep, people with this condition vastly underestimate their real time as measured by instruments.  They also overestimate the sleep latency period between bedtime and when they actually get to sleep. It has been found that individuals with sleep state misperception tend to have higher metabolic rates.

The International Classification of Sleep Disorders criteria uses the term sleep-state misrepresentation. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has no classification for this phenomenon.

It is not known what causes paradoxical insomnia or how prevalent it is.  Sometimes people who have had chronic insomnia, when they start sleeping normally, still have paradoxical insomnia.  It has been suggested that paradoxical insomnia is a precursor to psychophysiological insomnia

Psychophysiological insomnia

This is a term given when the insomnia is caused by a mix of physical and psychological factors.  Given sleep’s importance for our minds and bodies it is not surprising that multiple causes could contribute to sleep fragmentation.

A viscous cycle can start with a minor event that causes transient insomnia.  Rather than disappearing in a few days, the insomnia worsens as the sufferer worries about getting enough sleep.  Daytime sleepiness may prompt him or her to go to bed earlier, resulting in greater sleep latency and possible sleep onset insomnia.  The bed becomes associated, in the person’s mind, with a place of unrest and struggle for sleep.  Pills can be tried, but even if they work, they lead to rebound insomnia when stopped.  The person muddles on with new fixes, new bad feelings about the bedroom, and continued poor sleep.

Insomnia and menopause

Insomnia during pregnancy

Nosology - Formal Types of Insomnia

The International Classification of Sleep Disorders (ICSD) produced by the American Academy of Sleep Medicine (AASM), in its second edition (ICSD-2), lists 11 subtypes of insomnia.

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