Insomnia

Introduction:

Insomnia is defined as difficulty initiating, or maintaining sleep at least 3 nights per week, in addition to complaints of sleep related daytime impairment. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than 8 hours of sleep a day, but only 35% of American adults consistently get this amount of rest.

People with insomnia tend to experience one or more of the following sleep disturbances:

• Difficulty falling asleep at night
• Waking too early in the morning
• Waking frequently throughout the night
• Sleep that is chronically nonrestorative or poor

Insomnia may stem from a disruption of the body's circadian rhythm, an internal clock that governs the timing of hormone production, sleep, body temperature, and other functions. While occasional restless nights are normal, prolonged insomnia can interfere with daytime function, concentration, and memory. Insomnia increases the risk of substance abuse, motor vehicle accidents, headaches, and depression. Recent surveys indicate that 50% of people suffer from sleep difficulties, and 20 - 36% of them struggle with such difficulties for at least 1 year. Other studies show that one person out of three in the United States has insomnia, but only 20% tell their health care providers about it.

Signs and Symptoms:

Signs of insomnia may include:

• Not feeling refreshed after sleep
• Inability to sleep despite being tired
• Daytime drowsiness, fatigue, irritability, difficulty concentrating, and impaired ability to perform normal activities
• Anxiety as bedtime approaches
• Tension headaches

Causes:

No known physical or mental condition causes primary insomnia. Everyday anxiety and stress, coffee, and alcohol are the most common culprits.

An underlying medical or psychological condition, such as depression,, often causes secondary insomnia. Studies show that 40 - 60% of people who have insomnia show signs of depression.

About 50% of insomnia cases have no identifiable cause.

Some conditions or situations that commonly lead to insomnia include:

• Substance abuse -- consuming excessive amounts of caffeine, alcohol, recreational drugs, or certain prescription medications such as stimulants. Smoking can cause restlessness and quitting smoking may also cause temporary insomnia.
• Disruption of circadian rhythms -- shift work, travel across time zones, or vision loss. Circadian rhythms are regulated, in part, by release of a hormone called melatonin from the brain. As individuals age, less melatonin is available for use by the body.
• Menopause -- between 30 - 40% of menopausal women experience insomnia. This may be due to hot flashes, night sweats, anxiety, or fluctuations in hormone levels.
• Hormonal changes during menstrual cycle -- insomnia may occur during menstruation. Sleep improves mid-cycle with ovulation.
• Advanced age -- biological changes associated with aging, underlying medical conditions, and side effects from medications all contribute to insomnia.
• Medical conditions -- gastroesophageal reflux (return of stomach contents into the esophagus), fibromyalgia, other chronic pain syndromes, heart disease, arthritis, attention deficit hyperactivity disorder, and obstructive sleep apnea (difficulty breathing during sleep).
• Psychiatric and neurologic conditions -- anxiety, depression, manic depressive disorder, dementia, Parkinson's disease, restless legs syndrome, post-traumatic stress disorder.
• Certain medications -- decongestants (such as pseudoephedrine or Sudafed), bronchodilators (such as albuterol or Proventil inhaler), and beta-blockers (such as metoprolol or Lopressor).
• Excessive computer work.
• Partners who snore.

Risk Factors:

The following factors may increase an individual's risk for insomnia:

• Age -- the elderly are more prone to insomnia
• Gender -- women are more likely to have insomnia than men
• Stressful or traumatic event
• Night shift or changing work schedule
• Travel across time zones
• Substance abuse
• Asthma -- bronchodilators occasionally cause insomnia
• Excessive computer work
• Depression
• Sedentary lifestyle

Diagnosis:

Clinical history (including all current medication and recreational drug use) and physical exam are usually sufficient to make the diagnosis. Polysomnography, an overnight sleep study, can be helpful to rule out other types of sleep disorders (such as breathing related sleeping disorder).

Preventive Care:

The following lifestyle changes can help prevent insomnia:

• Exercising regularly -- best when done before dinner. Exercise should not be done too close to bedtime because it can cause restlessness.
• Avoiding caffeine (especially after noon) and nicotine.
• Getting regular exposure to late afternoon sun. This helps stimulate the release of melatonin to regulate circadian rhythm.
• Practicing stress reduction techniques, such as yoga, meditation, or deep relaxation.
• Early treatment of insomnia may also help prevent psychiatric disorders, such as depression.

Treatment:

The preferred treatments for people with chronic insomnia are lifestyle changes and behavioral approaches that establish healthy sleeping habits. This is called improving sleep hygiene.

Mind/body therapies -- such as stimulus control therapy, bright light therapy, and cognitive behavioral therapy -- are particularly helpful.

Acupuncture and acupressure have a long tradition of treating insomnia successfully, particularly in the elderly. Vitamins, along with homeopathic and herbal remedies, may also improve symptoms in some individuals.

Lifestyle

Healthy sleep habits are essential for treating insomnia. The following strategies (in addition to the steps mentioned in the "Preventive Care" section) may help treat the condition:

• Maintain a consistent sleeping and waking time.
• Establish the bedroom as a place for sleep and sexual activity only, not for reading, watching television, or working.
• Avoid naps, especially in the evening.
• Take a hot bath about 2 hours before bedtime.
• Keep the bedroom cool, well ventilated, quiet, and dark.
• Avoid looking at the clock -- this promotes anxiety and obsession about time.
• Avoid fluids just before bedtime.
• Avoid exercising before bedtime.
• Avoid television just before bedtime.
• Avoid caffeine in the later hours of the day.
• Eat a carbohydrate snack, such as cereal or crackers, just before bedtime.
• Move to another room with dim lighting if sleep does not occur within 15 - 20 minutes in bed.

Medications

If changes in sleep hygiene do not help, prescription medications (including benzodiazepines) may be appropriate. Benzodiazepines include temazepam (Restoril), flurazepam (Dalmane), estazolam (ProSom), and triazolam (Halcion). Benzodiazepines may cause psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short term memory problems, dry mouth, blurred vision, and irregular heart beat.

Another class of sedative hypnotic medications includes the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and fewer adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta).

Ramelteon (Rozerem) belongs to a new class of drugs called melatonin agonists. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize circadian rhythm and sleep/wake cycles. Side effects may include daytime sleepiness, dizziness, and fatigue.

Over the counter (OTC) antihistamines may be used short term for insomnia. Diphenhydramine (Benadryl) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl, Nytol, Sominex) or in combination with other OTC items, such as acetaminophen (Tylenol PM). Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation.

Generally, OTC and prescription medications help promote sleep, but they are not recommended for insomnia that lasts for more than 4 weeks. Long term use of some medications may cause addiction, particularly if the patient has a history of substance abuse.

Nutrition and Dietary Supplements

Following these nutritional tips may help reduce symptoms:

• Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
• Eat more antioxidant rich foods (such as green leafy vegetables) and fruits (such as blueberries, pomegranates, and cherries).
• Avoid refined foods, such as white breads, pastas, and sugar.
• Eat fewer red meats and more lean meats, cold water fish, or beans for protein.
• Use healthy cooking oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise 30 minutes daily, 5 days a week. Exercising in the evening after dinner may lead to insomnia.
• Foods rich in carbohydrates and low in protein and fat may boost the production of serotonin and melatonin, brain chemicals that are associated with sleep. A carbohydrate snack of granola, unsweetened cereals, or crackers with milk before bed may help.

The following dietary supplements may also be helpful in promoting sleep:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
• Omega 3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tbsp. oil 1 - 3 times daily, to help decrease inflammation and help with mental balance. Fish oil supplements can increase the blood thinning effect of many medications, so it's important to speak with your doctor before taking supplements.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
• 5-hydroxytryptophan (5-HTP), 50 mg 2 - 3 times daily, for mood stabilization and sleep improvement. See below for serious cautions and contraindications.
• L-theanine, 200 mg 1 - 3 times daily, for nervous system support.
• Melatonin, 1 - 6 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

L-tryptophan and 5-hydroxytryptophan (5-HTP)

Medical research indicates that taking 1 g L-tryptophan before bedtime can induce sleepiness and delay wake times. Researchers think L-tryptophan brings on sleep by raising levels of serotonin, a body chemical that promotes relaxation. However, consumers should take this supplement with caution as it may adversely interact with certain antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), and cause serious negative side effects. Reports of eosinophilia myalgia syndrome (EMS: an autoimmune disorder characterized by fatigue, fever, muscle pain and tenderness, cramps, weakness, hardened skin, and burning, tingling sensations in the extremities) from contaminated L-tryptophan supplements surfaced in 1989, and isolated incidents of EMS continue to be reported.

Studies also suggest that 5-hydroxytryptophan (5-HTP), made from tryptophan in the body or available in supplement form, may be useful in treating insomnia associated with depression. Like tryptophan, reports of EMS have been associated with use of 5-hydroxytryptophan. Talk to a health care professional before taking 5-HTP supplements if you are on antidepressant medications. Drug interactions may occur.

Melatonin

Melatonin supplements help induce sleep, particularly in people who have disrupted circadian rhythms (such as from jet lag or shift work), or those with low levels of melatonin (such as some people with schizophrenia). In fact, a review of scientific studies found that melatonin supplements help prevent jet lag, particularly in people who cross five or more time zones. A few clinical studies suggest that melatonin is significantly more effective than placebo, or dummy pill, in decreasing the amount of time required to fall asleep, increasing the number of sleeping hours, and boosting daytime alertness. Although research suggests that melatonin may be modestly effective for treating certain types of insomnia, few studies have investigated whether melatonin supplements are safe and effective for long term use. More research is needed.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted:

• Kava kava (Piper methysticum) standardized extract, 100 - 250 mg 1 - 3 times daily, as needed for relaxation. Kava should not be used in those with liver problems or those drinking alcohol in excessive quantities.
• Rhodiola (Rhodiola rosea) standardized extract, 100 - 600 mg daily, for antioxidant and antistress activity.
• Valerian (Valeriana sp.) standardized extract, 200 - 400 mg at bedtime, for sleep.
• Chamomile (Anthemis nobilis), standardized extract, 400 - 1,600 mg daily, for relaxation. A tea may be prepared from chamomile flowers. Chamomile is not recommended for individuals allergic to flowers in the daisy family.

Homeopathy

A few studies have examined the effectiveness of specific homeopathic remedies. However, a professional homeopath may recommend one or more of the following treatments for insomnia, based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Aconitum -- for insomnia that occurs as a result of illness, fever, or vivid, frightening dreams; commonly used for children.
• Argentum nitricum -- for impulsive children who are restless and agitated before bedtime and cannot fall asleep if the room is too warm.
• Arsenicum album -- for insomnia that occurs after midnight due to anxiety or fear. This remedy is most appropriate for demanding individuals who are often restless, thirsty, and chilly.
• Chamomilla -- for insomnia caused by irritability or physical pains; sleep may be disturbed by twitching and moaning. This remedy is appropriate for infants who have difficulty sleeping because they are teething or colicky, and older children may demand things, then refuse them when they are offered.
• Coffea -- for insomnia due to excitable news or sudden emotions. This remedy is most appropriate for individuals who generally have difficulty falling asleep and tend to be light sleepers. Often used to counteract the effects of caffeine, including in infants exposed to caffeine through breastfeeding.
• Ignatia -- for insomnia caused by grief or recent loss. This remedy is most appropriate for individuals who yawn frequently or sigh while awake.
• Kali phosphoricum -- for night terrors associated with insomnia. This remedy is most appropriate for individuals who are easily startled and restless, often with fidgety feet. Anxiety is often caused by both nightmares and events in the individual's life.
• Nux vomica -- for insomnia caused by anxiety, anger, irritability, or use of caffeine, alcohol, or drugs. This remedy is most appropriate for individuals who wake up early in the morning, or for children who often have dreams of school or fights and may be awakened by slight disturbances. Nux vomica may also be used to treat insomnia that occurs as a side effect of medications.
• Passiflora -- for the elderly and young children with often overactive minds.
• Pulsatilla -- for women and children who are particularly emotional and do not like sleeping alone. Also used when sleeping in a warm room tends to worsen insomnia or when the individual may cry due to the inability to fall asleep.
• Rhus toxicodendron -- for restlessness and insomnia caused by pains that occur when the individual is lying down.

Acupuncture

Some reports suggest that certain acupuncture procedures have a nearly 90% success rate for the treatment of insomnia. Through a complex series of signals to the brain, acupuncture increases the amount of certain substances in the brain, such as serotonin, which promote relaxation and sleep.

Several clinical studies have found that auricular acupuncture is effective in reducing symptoms of insomnia, such as difficultly in falling asleep and remaining asleep. Auricular acupuncture uses needles placed at various points in the ear. Further studies should be performed.

Clinical studies of elderly people with sleep disturbances suggest that acupressure enhances sleep quality and decreases awakenings during the night. An acupressure practitioner works with the same points used in acupuncture, but stimulates these healing sites with finger pressure, rather than inserting fine needles. Clinical studies support the use of auricular (ear) acupressure for improving sleep quality in elderly patients and possibly in healthy adults of all ages. A small clinical study also found that acupressure may help with sleep apnea.

Chiropractic

No well designed studies have evaluated the effect of chiropractic care on individuals with insomnia, but chiropractors report that spinal manipulation may improve symptoms of the condition in some individuals. In these cases, spinal manipulation may have a relaxing effect on the nervous system.

Massage and Aromatherapy

Massage has long been known to enhance relaxation and improve sleep patterns. While massage alone is an effective method for relaxation, studies suggest that massage with essential oils (called aromatherapy), particularly lavender (Lavandula angustifolia), may result in improved sleep quality, more stable mood, increased mental capacity, and reduced anxiety. Clinical studies have found participants who received massage with lavender felt less anxious and more positive than participants who received massage alone.

Mind/Body Medicine

A variety of behavioral techniques have proved helpful in treating insomnia. These methods, with the guidance of a sleep specialist or a sleep specialty team, are singly used to treat insomnia, but they may also be combined with other treatment methods including:

• Sleep Diary. Keeping a daily/nightly record of sleep habits (including the amount of sleep, how long it takes to fall asleep, the quality of sleep, the number of awakenings throughout the night, any disruption of daytime behaviors, attempted treatments and how well they worked, mood, and stress level) can help a person understand and consequently overcome their insomnia.
• Stimulus Control Techniques. This technique involves learning to use the bedroom only for sleep and sexual activity. Individuals using this technique learn to go to bed only when tired and leave the bedroom when they’re not sleeping. They wake up at the same time every day, including weekends and vacations, regardless of the amount of sleep they had.
• Sleep Restriction. This method improves sleep "efficiency" by attempting to spend at least 85% of time in bed asleep. The time spent in bed is decreased each week by 15 - 20 minutes until the 85% goal is achieved. Once accomplished, the amount of time in bed is increased again on a weekly basis.
• Relaxation Training Techniques. Progressive relaxation, meditation, yoga, guided imagery, hypnosis, or biofeedback can break the vicious cycle of sleeplessness by decreasing feelings of anxiety about not being asleep. Studies indicate that these therapies significantly reduce the amount of time it takes to fall asleep, increase total sleep time, and decrease the number of nightly awakenings.
• Cognitive Behavioral Therapy. This therapy is intended to re-establish healthy sleep patterns by helping an individual cope with their sleep problem. One cognitive behavioral approach, called paradoxical intention, helps to retrain an individual's fears of sleep by doing the opposite of the behavior that causes anxiety. Long before going to bed, for example, a person with insomnia worries about not being able to sleep and the difficulty they will have at bedtime. Rather than preparing to go to sleep, the person prepares to stay awake. Another cognitive behavioral technique, called thought stopping, allows a person with insomnia a certain period of time to repeatedly and continuously think about going to bed. This technique helps "wear out" the anxiety associated with going to bed, and decreases the likelihood that they will obsess about falling asleep at other times.

Traditional Chinese Medicine

Many methods have been used historically in Traditional Chinese Medicine to treat insomnia, including herbal remedies, acupuncture, acupressure, Chinese massage (tui na), and qi gong.

Other Considerations:

Pregnancy

• Insomnia usually occurs in the later months of pregnancy when the mother's size and need to urinate disrupt sleep.
• Women who are pregnant and nursing mothers should avoid benzodiazepines.

Warnings and Precautions

• People who are taking prescription medications or over the counter sleeping pills should avoid alcohol.
• Discontinuing prescription medications or over the counter sleeping pills can lead to rebound insomnia.

Prognosis and Complications

Most people who have insomnia with no underlying medical conditions recover within a few weeks. For those who develop insomnia from a traumatic event (such as those with posttraumatic stress disorder), sleep disruptions can continue indefinitely. People who become dependent on sleeping pills and prescription medication for sleep often have the most difficulty overcoming insomnia. Chronic insomnia can encourage the development of a medical condition, a mental disorder, and road, work, and domestic accidents.

Alternative Names:

Sleeplessness