the circadian rhythm based on core temperature. increased beta activity and decreased delta wave activity has been observed on electroencephalograms; however, the implication of this is unknown. around half of post-menopausal women experience sleep disturbances, and generally sleep disturbance is about twice as common in women as men; this appears to be due in part, but not completely, to changes in hormone levels, especially in and post-menopause. changes in sex hormones in both men and women as they age may account in part for increased prevalence of sleep disorders in older people. diagnosis in medicine, insomnia is widely measured using the athens insomnia scale. it is measured using eight different parameters related to sleep, finally represented as an overall scale which assesses an individual's sleep pattern. a qualified sleep specialist should be consulted for the diagnosis of any sleep disorder so the appropriate measures can be taken. past medical history and a physical examination need to be done to eliminate other conditions that could be the cause of insomnia. after all other conditions are ruled out a comprehensive sleep history should be taken. the sleep history should include sleep habits, medications (prescription and non-prescription), alcohol consumption, nicotine and caffeine intake, co-morbid illnesses, and sleep environment. a sleep diary can be used to keep track of the individual's sleep patterns. the diary should include time to bed, total sleep time, time to sleep onset, number of awakenings, use of medications, time of awakening, and subjective feelings in the morning. the sleep diary can be replaced or validated by the use of out-patient actigraphy for a week or more, using a non-invasive device that measures movement. workers who complain of insomnia should not routinely have polysomnography to screen for sleep disorders. this test may be indicated for patients with symptoms in addition to insomnia, including sleep apnea, obesity, a thick neck diameter, or high-risk fullness of the flesh in the oropharynx. usually, the test is not needed to make a diagnosis, and insomnia especially for working people can often be treated by changing a job schedule to make time for sufficient sleep and by improving sleep hygiene. some patients may need to do an overnight sleep study to determine if insomnia is present. such a study will commonly involve assessment tools including a polysomnogram and the multiple sleep latency test. specialists in sleep medicine are qualified to diagnose disorders within the, according to the icsd, 81 major sleep disorder diagnostic categories. patients with some disorders, including delayed sleep phase disorder, are often mis-diagnosed with primary insomnia; when a person has trouble getting to sleep and awakening at desired times, but has a normal sleep pattern once asleep, a circadian rhythm disorder is a likely cause. in many cases, insomnia is co-morbid with another disease, side-effects from medications, or a psychological problem. approximately half of all diagnosed insomnia is related to psychiatric disorders. for those who have depression, "insomnia should be regarded as a co-morbid condition, rather than as a secondary one;" insomnia typically predates psychiatric symptoms. "in fact, it is possible that insomnia represents a significant risk for the development of a subsequent psychiatric disorder." insomnia occurs in between 60% and 80% of people with depression. this may partly be due to treatment used for depression. determination of causation is not necessary for a diagnosis. dsm-5 criteria the dsm-5 criteria for insomnia include the following: predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: difficulty initiating sleep. (in children, this may manifest as difficulty initiating sleep without caregiver intervention.) difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (in children, this may manifest as difficulty returning to sleep without caregiver intervention.) early-morning awakening with inability to return to sleep. in addition: the sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. the sleep difficulty occurs at least three nights per week. the sleep difficulty is present for at least three months. the sleep difficulty occurs despite adequate opportunity for sleep. the insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia). the insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). types insomnia can be classified as transient, acute, or chronic. transient insomnia lasts for less than a week. it can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe depression, or by stress. its consequences – sleepiness and impaired psychomotor performance – are similar to those of sleep deprivation. acute insomnia is the inability to consistently sleep well for a period of less than a month. insomnia is present when there is difficulty initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality. these problems occur despite adequate opportunity and circumstances for sleep and they must result in problems with daytime function. acute insomnia is also known as short term insomnia or stress related insomnia. chronic insomnia lasts for longer than a month. it can be caused by another disorder, or it can be a primary disorder. common causes of chronic insomnia include persistent stress, trauma, work schedules, poor sleep habits, medications, and other mental health disorders. people with high levels of stress hormones or shifts in the levels of cytokines are more likely than others to have chronic insomnia. its effects can vary according to its causes. they might include muscular weariness, hallucinations, and/or mental fatigue. prevention prevention and treatment of insomnia may require a combination of cognitive behavioral therapy, medications, and lifestyle changes. among lifestyle practices, going to sleep and waking up at the same time each day can create a steady pattern which may help to prevent insomnia. avoidance of vigorous exercise and caffeinated drinks a few hours before going to sleep is recommended, while exercise earlier in the day may be beneficial. other practices to improve sleep hygiene may include: avoiding or limiting naps treating pain at bedtime avoiding large meals, beverages, alcohol, and nicotine before bedtime finding soothing ways to relax into sleep, including use of white noise making the bedroom suitable for sleep by keeping it dark, cool, and free of devices, such as clocks, cell phones, or televisions maintain regular exercise try relaxing activities before sleeping management it is recommended to rule out medical and psychological causes before deciding on the treatment for insomnia. cognitive behavioral therapy is generally the first line treatment once this has been done. it has been found to be effective for chronic insomnia. the beneficial effects, in contrast to those produced by medications, may last well beyond the stopping of therapy. medications have been used mainly to reduce symptoms in insomnia of short duration; their role in the management of chronic insomnia remains unclear. several different types of medications may be used. many doctors do not recommend relying on prescription sleeping pills for long-term use. it is also important to identify and treat other medical conditions that may be contributing to insomnia, such as depression, breathing problems, and chronic pain. as of 2022, many people with insomnia were reported as not receiving overall sufficient sleep or treatment for insomnia. non-medication based non-medication based strategies have comparable efficacy to hypnotic medication for insomnia and they may have longer lasting effects. hypnotic medication is only recommended for short-term use because dependence with rebound withdrawal effects upon discontinuation or tolerance can develop. non medication based strategies provide long lasting improvements to insomnia and are recommended as a first line and long-term strategy of management. behavioral sleep medicine (bsm) tries to address insomnia with non-pharmacological treatments. the bsm strategies used to address chronic insomnia include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, paradoxical intention, patient education, and relaxation therapy. some examples are keeping a journal, restricting the time spent awake in bed, practicing relaxation techniques, and maintaining a regular sleep schedule and a wake-up time. behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. behavioral therapy may include, learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies and regulating the circadian clock. music may improve insomnia in adults (see music and sleep). eeg biofeedback has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as quality of sleep. self-help therapy (defined as a psychological therapy that can be worked through on one's own) may improve sleep quality for adults with insomnia to a small or moderate degree. stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. as stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of sleep hygiene. examples of such environmental modifications include using the bed for sleep and sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not occur in a reasonably brief period of time after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during night-time hours, and eliminating daytime naps. a component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with actual time spent asleep. this technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation. complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when sleep efficiency improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock. bright light therapy may be effective for insomnia. paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). one theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. this technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs). sleep hygiene sleep hygiene is a common term for all of the behaviors which relate to the promotion of good sleep. they include habits which provide a good foundation for sleep and help to prevent insomnia. however, sleep hygiene alone may not be adequate to address chronic insomnia. sleep hygiene recommendations are typically included as one component of cognitive behavioral therapy for insomnia (cbt-i). recommendations include reducing caffeine, nicotine, and alcohol consumption, maximizing the regularity and efficiency of sleep episodes, minimizing medication usage and daytime napping, the promotion of regular exercise, and the facilitation of a positive sleep environment. the creation of a positive sleep environment may also be helpful in reducing the symptoms of insomnia. on the other hand, a systematic review by the aasm concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as cbt-i should be preferred. cognitive behavioral therapy main article: cognitive behavioral therapy for insomnia there is some evidence that cognitive behavioral therapy for insomnia (cbt-i) is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia. in this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. common misconceptions