Chronic kidney disease and the global public health agenda: an international consensus

Insomnia: Causes, Treatments, And Why It Matters

Insomnia is a common sleep disorder and one of the most common sleep problems in adults worldwide. As part of the broader category of sleep disorders, insomnia is characterized by symptoms of insomnia such as trouble falling asleep, trouble sleeping through the night, waking up too early and daytime impairments.

Unlike those who sleep well, people with insomnia struggle to get the rest they need. This sleep disorder can be short term insomnia—often triggered by stressful life events and lasts a few days to weeks or long term insomnia—a chronic condition that can interfere with daily living.

The effects of insomnia are daytime sleepiness, feeling tired when waking and reduced mental clarity and physical energy. People with insomnia report trouble sleeping and trouble falling asleep which can lead to ongoing fatigue and overall wellbeing. As researchers continue to unravel this complex condition, there's growing consensus it's more than just "bad sleep"—it's a multi-factorial disorder with public health implications.

Table of ContentsPrevalence and Public Health Impact

Insomnia is super common. Large studies estimate up to 10% of adults meet criteria for insomnia disorder—a clinical diagnosis of persistent sleep difficulties. Rates are even higher for short term or occasional episodes [7] [10] [13].

It's one of the most common health complaints in primary care. Insomnia often co-occurs with mental health conditions and mental health disorders such as depression and anxiety, highlighting the link between sleep and mental wellbeing. A 2021 global cross-sectional study linked insomnia to a wide range of psychiatric conditions including anxiety, mood disorders and substance use disorders [13].

Beyond mental health, poor sleep can also impact physical wellbeing. Chronic insomnia has been linked to increased risk of hypertension, diabetes and cardiovascular disease [8] [9]. In some cases insomnia may be caused or worsened by an underlying medical condition such as an overactive thyroid. Untreated insomnia can also contribute to chronic pain and further impact quality of life.

Lack of quality sleep affects everything from hormone balance to immune system function, making insomnia a key player in overall health—not just a bedtime nuisance. Public health strategies that promote good sleep hygiene and early intervention can prevent insomnia and reduce its long term impact.

Root Causes: A Multi-Factorial Disorder

Insomnia isn't a single disease—it's a syndrome with many parts. There are different types including primary insomnia which occurs without an underlying medical condition and secondary insomnia which is caused by other health issues or factors. Acute insomnia is a short term form that lasts from one night to a few weeks often triggered by stressful life events or changes in routine.

Genetics, stress, mental health issues, medical conditions and even poor sleep habits can all play a role. Other sleep disorders such as sleep apnea or restless legs syndrome may need to be ruled out during assessment. Review of medical history and identifying risk factors are essential steps in diagnosing insomnia. Disruptions in the sleep wake cycle or sleep cycle can also contribute to sleep difficulties.

Modifiable factors like sleep hygiene—behavioural and environmental practices that promote healthy sleep—are important to address. Lifestyle contributors such as the decision to drink alcohol can negatively impact sleep quality and worsen insomnia.

Specialists in internal medicine are often involved in evaluating and managing these complex cases. According to a foundational review published in JAMA [1] treating insomnia effectively requires addressing these multiple underlying contributors.

A newer concept gaining traction is "personomics"—the idea that treatment should be tailored to an individual's unique sleep patterns, routines and challenges [3]. This shift towards personalized insomnia care reflects a broader trend in medicine to treat the person not just the symptoms.

Gold Standard Treatment: Cognitive Behavioural Therapy for Insomnia (CBT-I)

The gold standard treatment across all guidelines is Cognitive Behavioural Therapy for Insomnia (CBT-I). It's non-drug, evidence-based and aims to treat insomnia by changing the unhelpful thoughts and behaviours that keep people stuck in poor sleep cycles [1] [2] [5] [6].

CBT-I is also effective for anxiety disorders making it a versatile tool in mental health care. As part of insomnia treatment patients typically learn techniques like sleep restriction, stimulus control and relaxation training—all proven to improve sleep quality. Keeping a regular sleep schedule and using a sleep diary to track progress are key strategies to help individuals fall asleep and stay asleep.

But access is a barrier. Complementary and integrative health approaches can be used as adjuncts or alternatives to CBT-I for those seeking holistic insomnia treatment. In some cases prescription drugs may be considered when CBT-I is not available or as part of a broader treatment plan.

A 2025 randomised controlled trial found inpatient CBT-I significantly reduced insomnia severity compared to outpatient care [14] hinting at the need for more robust service delivery. Unfortunately a shortage of trained providers continues to limit widespread use [2].

Pharmacologic and Complementary Therapies

While behavioural therapy is the first line approach, medications are used for short term relief especially when symptoms are severe or CBT-I is not available. Pharmacologic options include sleeping pills, prescription sleep aids and other sleep medications which can help people fall asleep and address trouble falling asleep. These sleep aids which also include non-prescription options carry risks of dependence, daytime drowsiness and rebound insomnia [1].

Before starting medication a thorough assessment is recommended. This may involve a sleep study conducted at a sleep centre to diagnose insomnia and confirm the insomnia diagnosis and rule out other sleep disorders.

Meanwhile researchers are exploring safer alternatives. A 2025 experimental study found that Jujuboside A, a natural compound derived from the jujube plant, restored mitochondrial function in brain cells and reduced insomnia symptoms in animal models [12]. More human trials are needed before widespread use.

Insomnia and Mental and Cardiovascular Health

There's a two-way street between insomnia and mental health. A 2025 network analysis found that people with insomnia experience a complex web of symptoms: depression, anxiety, stress and cognitive difficulties [11]. These aren't side effects—they're part of the condition itself.

Insomnia often co-occurs with mental health disorders so comprehensive treatment is essential. For patients with comorbid conditions treatment may include prescription drugs which should be managed by a healthcare provider.

Insomnia also has cardiovascular implications. A 2021 study found that people with sleep-onset insomnia had reduced vagal tone and impaired baroreflex sensitivity both of which are essential for heart function [9]. In other words your heart pays the price when your sleep suffers.

Sleep apnea is another sleep disorder that can impact cardiovascular health and symptoms of insomnia may overlap with other sleep disorders. This highlights the need for differential diagnosis to rule out or identify conditions such as sleep apnea, restless legs syndrome or narcolepsy.

This growing body of evidence is changing how clinicians view insomnia—not as an isolated complaint but as a central health issue that can amplify other medical problems.

The Future: Clinical Gaps and Research Needs

Despite decades of attention many questions remain. A 2021 narrative review called for better quantification of the societal and economic costs of insomnia and investment in treatments that are safe and scalable [4]. Future research should also focus on long term insomnia given its significant health impacts and chronic nature.

Meanwhile a 2022 review urged the medical community to dig deeper into the neurobiology of insomnia—particularly how brain circuits governing arousal and rest interact and the importance of understanding the sleep cycle in this context [5].

Personalized sleep apps, AI-based diagnostics and digital CBT-I platforms offer new pathways forward. Research tools such as the sleep diary and sleep study are essential for tracking sleep patterns and diagnosing underlying disorders often conducted in a sleep centre which also serves as a site for clinical trials and research. But real progress will depend on funding, awareness and equitable access to care.

Closing Thoughts

Insomnia is more than just occasional restlessness—it's a common, underdiagnosed and undertreated condition with far reaching impact on mental, cardiovascular and public health. While CBT-I is the gold standard, new approaches—natural compounds, digital therapies and personalized treatment plans—are opening up new possibilities.

As science advances so must our thinking. Sleep health is not a luxury—it's a foundation of wellbeing that deserves a place at the top of our health system.

References

[1] Buysse D. J. (2013). Insomnia. JAMA, 309(7), 706–716. Https://doi.Org/10.1001/jama.2013.193

[2] Burman D. (2017). Sleep Disorders: Insomnia. FP essentials, 460, 22–28. Https://pubmed.Ncbi.Nlm.Nih.Gov/28845958/

[3] Porosnicu Rodriguez, K. A., Salas, R. M. E., & Schneider, L. (2023). Insomnia: Personalized Diagnosis and Treatment Options. Neurologic clinics, 41(1), 1–19. Https://doi.Org/10.1016/j.Ncl.2022.07.004

[4] Roach, M., Juday, T., Tuly, R., Chou, J. W., Jena, A. B., & Doghramji, P. P. (2021). Challenges and opportunities in insomnia disorder. The International journal of neuroscience, 131(11), 1058–1065. Https://doi.Org/10.1080/00207454.2020.1773460

[5] Riemann, D., Benz, F., Dressle, R. J., Espie, C. A., Johann, A. F., Blanken, T. F., Leerssen, J., Wassing, R., Henry, A. L., Kyle, S. D., Spiegelhalder, K., & Van Someren, E. J. W. (2022). Insomnia disorder: State of the science and challenges for the future. Journal of sleep research, 31(4), e13604. Https://doi.Org/10.1111/jsr.13604

[6] Sutton E. L. (2021). Insomnia. Annals of internal medicine, 174(3), ITC33–ITC48. Https://doi.Org/10.7326/AITC202103160

[7] Roth, T., & Roehrs, T. (2003). Insomnia: epidemiology, characteristics, and consequences. Clinical cornerstone, 5(3), 5–15. Https://doi.Org/10.1016/s1098-3597(03)90031-7

[8] Cunnington, D., Junge, M. F., & Fernando, A. T. (2013). Insomnia: prevalence, consequences and effective treatment. The Medical journal of Australia, 199(8), S36–S40. Https://doi.Org/10.5694/mja13.10718

[9] Tsai, H. J., Kuo, T. B. J., Yang, A. C., Tsai, S. J., & Yang, C. C. H. (2021). Difficulty in initiating sleep is associated with poor morning cardiovascular function. Psychiatry research, 295, 113518. Https://doi.Org/10.1016/j.Psychres.2020.113518

[10] Morin, C. M., & Jarrin, D. C. (2022). Epidemiology of Insomnia: Prevalence, Course, Risk Factors, and Public Health Burden. Sleep medicine clinics, 17(2), 173–191. Https://doi.Org/10.1016/j.Jsmc.2022.03.003

[11] Carpi, M., Marques, D. R., & Liguori, C. (2025). Unraveling the insomnia web: a network analysis of insomnia and psychological symptoms in good and poor sleepers among young adults. Sleep medicine, 132, 106590. Https://doi.Org/10.1016/j.Sleep.2025.106590

[12] Zhang, Z., Che, X., Feng, T., Zou, J., Chen, G., Guo, W., Ma, C., Yuan, H., Chen, J., & Xu, X. (2025). Jujuboside A improves insomnia by maintaining mitochondrial homeostasis in prefrontal neurons. Brain research bulletin, 226, 111372. Https://doi.Org/10.1016/j.Brainresbull.2025.111372

[13] Aernout, E., Benradia, I., Hazo, J. B., Sy, A., Askevis-Leherpeux, F., Sebbane, D., & Roelandt, J. L. (2021). International study of the prevalence and factors associated with insomnia in the general population. Sleep medicine, 82, 186–192. Https://doi.Org/10.1016/j.Sleep.2021.03.028

[14] Li, G., Li, M., Xu, X., Zhang, J., Li, Q., & Cai, Q. (2025). Inpatient vs outpatient cognitive behavioral therapy for insomnia: A two-arm parallel randomized controlled trial. Comprehensive psychiatry, 141, 152609. Advance online publication. Https://doi.Org/10.1016/j.Comppsych.2025.152609

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Are You Seeking Attention, Or Do You Have Histrionic Personality Disorder?

Do You Have Histrionic Personality Disorder? FreshSplash - Getty Images

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BEING EXCESSIVELY EMOTIONAL, behaving provocatively with people you barely know, and striving to always be the center of attention may describe someone you know. This person might be incredibly fun to be around sometimes, and really embarrassing at other times.

In extreme cases, these behaviors can be signs of histrionic personality disorder (HPD).

The American Psychiatric Association characterizes the disorder as "excessive emotion and attention-seeking." People with HPD might feel uncomfortable when they're not the center of attention, use their physical appearance to attract attention to themselves, and have exaggerated or quickly changing emotions.

"Folks with HPD might be quite captivating to others as they come across as charming, enthusiastic, lively, and seductive," says Kelly Workman, PsyD, BCBA, licensed clinical psychologist and founder of Mindset Wellness and Consulting.

Theatrical behavior, shallowness, egocentricity, and being easily hurt by others are other characteristics of HPD. "They're highly concerned with impressing others and subsequently will engage in behaviors that put them at the center of attention," she says.

But, it's important to note that just because someone loves being the center of attention and may act overdramatic sometimes, it doesn't necessarily mean they have a personality disorder, Workman emphasizes. A person must display a pattern of these behaviors that's chronic and pervasive, and interferes with certain aspects of their life.

HPD is one of 10 clinically diagnosable personality disorders, but you might not hear about it as much as others, like narcissistic or obsessive-compulsive disorder. But, it did make headlines during the Johnny Depp-Amber Heard defamation trial in the summer of 2022. A psychologist hired by Depp said Heard had HBD and borderline personality disorders.

What Is Histrionic Personality Disorder?

The term "histrionic" means "dramatic or theatrical," and HPD is sometimes known as dramatic personality disorder.

People with HPD tie their self-esteem to the approval of others, rather than their own self-worth, according to Cleveland Clinic. They want to be noticed, so much so, that they'll behave dramatically or inappropriately—and, they might not realize their behavior or thoughts are problematic.

HPD is categorized as a Cluster B personality disorder, which involves dramatic, excitable, erratic, or volatile behavior. Narcissistic, borderline, and antisocial personality disorders are in the Cluster B group, too.

Signs of HPD include:

Needing to be the center of attention—and feeling under-appreciated and depressed when they're not

Constantly seeking the approval of others

Having quickly changing and shallow emotions

Displaying dramatic or extremely emotional behavior—to the point where it's embarrassing to others

Exhibiting a larger-than-life personality

Being flirtatious or persistently charming

Being overly concerned with physical appearance

Using their physical appearance to attract attention

Behaving sexually inappropriate with others, including strangers

Being easily influenced by others

Believing relationships are closer than they are—and, struggling to maintain relationships

Seeking instant gratification—and becoming bored or frustrated easily

"There are many extraverted individuals who are also impulsive, but this is not the same as HPD," Workman says. "Many individuals will display traits of personality disorders, but not actually meet the criteria for a personality disorder."

Behaviors are considered a personality disorder when the pattern is chronic and pervasive across different personal and social situations and creates significant distress in other areas of functioning, she says. And, the behaviors usually begin by the time someone reaches early adulthood.

The exact cause of HPD isn't known, but it's likely linked to genetics, childhood abuse or other trauma, and having parents who lack boundaries, are overindulgent, or are inconsistent, according to Cleveland Clinic.

How It Differs from Narcissism

HPD and narcissistic personality disorders are different, but they have some overlapping characteristics. Both are Cluster B disorders and feature erratic and dramatic behavior.

"While individuals with narcissistic personality disorder also crave attention, it tends to be driven by a desire to be recognized and acknowledged as superior as this relates to their inflated sense of self-worth," Workman says.

People with HPD are willing to be seen as fragile or dependent if they'll receive attention for it, she explains.

What It's Like to Live With Histrionic Personality Disorder

Relationships are tough for people with HPD. Emotional intimacy is difficult for them, as they sometimes perceive relationships to be closer than they truly are. Their emotions or interactions may also come across as fake or shallow.

"They may vacillate between wanting to control their partner and being overly dependent on their partner," Workman says. "Their constant need for attention may lead to alienating their friends. They might become easily bored with routines and have difficulties tolerating delayed gratification."

People with HPD often struggle with depression when they're not getting enough attention, she says. They're also at a greater risk of making suicidal gestures and threats to get attention. They might also have somatic symptoms disorder, where someone focuses on physical pain or illness for attention, or conversion disorder, where someone displays symptoms like blindness or paralysis that can't be explained medically.

"Often, individuals with personality disorders have difficulties recognizing the impact that their behavior has on others, which can lead to difficulties in various aspects of life," Workman says.

How Is the Disorder Treated?

People with HPD experience significant distress and need treatment, Workman says. But, there isn't a specific treatment for the disorder.

Cognitive behavioral therapy (CBT) has been helpful for many personality disorders, though, she adds. "CBT-based treatments will focus on identifying targets for behavior change and identify ways to shift patterns of thinking."

Workman says small studies have shown that some HPD patients improved after functional analytic psychotherapy, where therapists focus on what happens during therapy sessions to shape interpersonal behaviors, emotional awareness, and self-expression, and clarification-oriented psychotherapy, which focuses on self-regulation and motivation in interpersonal interactions and relationships.

"There is no cure for HPD," Workman says. "However, individuals can go on to live meaningful and productive lives. Those who participate in therapy tend to have better outcomes."

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The Silent Stress Symptoms That Could Be Slowly Killing You

Stress doesn't always announce itself with loud alarms; often, it creeps in silently, manifesting through subtle symptoms that are easy to overlook. Over time, these quiet signals can erode your health, leading to serious consequences if left unaddressed. Recognizing these signs is the first step toward safeguarding your well-being.

1. Chronic Fatigue That Doesn't Improve With Rest

i got ghosted and it hurts

Persistent exhaustion, even after a full night's sleep, can be a telltale sign of chronic stress. This type of fatigue isn't merely physical; it's a deep-seated tiredness that rest doesn't alleviate. According to the Mayo Clinic, chronic stress can disrupt sleep patterns and deplete your energy, leading to ongoing fatigue.

Over time, this constant tiredness can impair your ability to function effectively, affecting your work, relationships, and overall quality of life. It's essential to recognize this symptom early and implement stress-reduction strategies to prevent further health deterioration.

2. More Frequent Headaches And Migraines

Regular headaches or migraines can be more than just a nuisance; they might be your body's way of signaling stress overload. Tension headaches, in particular, are commonly linked to stress and anxiety. Stress can cause muscle tension and changes in brain chemicals, leading to headaches.

Ignoring these headaches can lead to chronic pain and decreased productivity. Incorporating relaxation techniques, such as deep breathing or meditation, can help alleviate stress and reduce the frequency of stress-induced headaches.

3. Digestive Issues Without A Clear Cause

Experiencing stomachaches, bloating, or changes in bowel habits without any apparent reason can be a silent sign of stress. Stress affects the digestive system by altering gut motility and increasing inflammation. As outlined by UCLA Health, chronic stress can lead to gastrointestinal problems like irritable bowel syndrome (IBS).

These digestive issues can significantly impact your comfort and nutrition. Addressing stress through dietary changes, exercise, and mindfulness practices can improve gut health and overall well-being.

4. Unexplained Weight Fluctuations

woman scrutinizing appearance in mirror

Sudden weight gain or loss without changes in diet or exercise routines can be attributed to stress. Stress hormones like cortisol can influence appetite and fat storage, leading to weight changes. Chronic stress can contribute to unhealthy eating behaviors and metabolic disturbances.

Monitoring your weight and being mindful of stress-related eating patterns is crucial. Implementing stress management techniques can help maintain a healthy weight and prevent related health issues.

5. Skin Problems And Breakouts

Stress doesn't just affect your internal health; it can manifest on your skin as acne, eczema, or psoriasis flare-ups. The skin's response to stress involves inflammation and increased oil production, leading to various dermatological issues. As the American Academy of Dermatology explains, stress can exacerbate existing skin conditions and trigger new ones.

Taking care of your skin involves more than topical treatments; managing stress is a vital component. Incorporating relaxation techniques and seeking professional help when needed can improve both your skin and overall health.

6. Getting Sick More Often

woman on the couch with a cold

If you find yourself catching colds or infections more frequently, stress might be compromising your immune system. Chronic stress can suppress immune function, making it harder for your body to fight off pathogens. This increased vulnerability can lead to more frequent and prolonged illnesses.

Strengthening your immune system involves more than just vitamins; reducing stress through healthy lifestyle choices is equally important. Regular exercise, adequate sleep, and stress-reduction techniques can bolster your body's defenses.

7. Persistent Muscle Tension Or Pain

Shot of a young man experiencing elbow pain in a gym

Ongoing muscle tension, especially in the neck, shoulders, or back, can be a physical manifestation of stress. Stress causes muscles to contract, leading to discomfort and pain over time. As noted by the American Psychological Association, chronic stress can result in musculoskeletal issues due to prolonged muscle tension.

Ignoring this tension can lead to chronic pain conditions and reduced mobility. Incorporating regular physical activity, stretching, and relaxation techniques can alleviate muscle tension and improve overall health.

8. Difficulty Concentrating And Memory Problems

Struggling to focus or experiencing memory lapses can be cognitive signs of stress. Stress affects the brain's ability to process information and retain memories. Chronic stress can impair cognitive functions, including attention and memory.

These cognitive issues can impact your performance at work or school. Engaging in stress-reduction activities and seeking professional support can help restore cognitive function and mental clarity.

9. Changes In Libido

Sad,Asian,Mature,Woman,Lonely,At,Home,Self,Isolation,Quarantine

A decrease in sexual desire or performance can be linked to stress. Stress affects hormone levels, which can influence libido and sexual function. Chronic stress can lead to reduced sexual interest and satisfaction.

Addressing stress through open communication with partners and stress management techniques can improve sexual health. If issues persist, consulting a healthcare provider is recommended.

10. Sleep Disturbances

Difficulty falling asleep, staying asleep, or experiencing restless sleep can be signs of stress. Stress activates the body's fight-or-flight response, making relaxation and sleep challenging. Stress-related sleep problems can lead to fatigue and decreased overall health.

Establishing a calming bedtime routine and practicing relaxation techniques can improve sleep quality. If sleep disturbances continue, seeking professional advice is important.

11. Mood Swings And Irritability

Experiencing sudden mood changes or increased irritability can be emotional indicators of stress. Stress affects neurotransmitters in the brain, influencing mood and emotional responses. Chronic stress can lead to mood disorders like depression and anxiety.

Recognizing these emotional changes and implementing stress-reduction strategies can improve mental health. Professional support may be necessary for persistent mood disturbances.

12. Jaw Clenching And Teeth Grinding

Unconscious behaviors like jaw clenching or teeth grinding, especially during sleep, can be stress-related. These actions can lead to dental issues and jaw pain over time. Stress is a common cause of bruxism (teeth grinding).

Using a mouthguard at night and practicing stress management can alleviate these symptoms. Consulting a dentist for persistent issues is advisable.

13. Social Withdrawal

Pulling away from friends and family or losing interest in social activities can be a behavioral sign of stress. Stress can lead to feelings of overwhelm, making social interactions seem daunting. Chronic stress can result in social withdrawal and isolation.

Maintaining social connections is vital for mental health. Reaching out to loved ones and seeking support can help combat the isolating effects of stress.

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