Insomnia

Insomnia is the inability to sleep during a period in which sleep should normally occur. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than eight hours of sleep per day and 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: (1) difficulty falling asleep at night, (2) waking too early in the morning, or (3) waking frequently throughout the night. 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 often normal, prolonged insomnia can interfere with daytime function, and may impair concentration, diminish memory, and increase the risk of substance abuse, motor vehicle accidents, headaches, and depression. Recent surveys indicate that at least one out of three people in the United States have insomnia, but only 20% bring it to the attention of their physicians.

Signs and Symptoms

Common symptoms of insomnia 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

Causes

Insomnia is occasionally a symptom of an underlying medical or psychological condition, but it may also be caused by stress (from work, school, or family) or lifestyle choices, such as excessive coffee and alcohol consumption. 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; smoking can cause restlessness and smoking cessation may also result in temporary insomnia
• Disruption of circadian rhythms—shift work, travel across time zones, or vision loss; circadian rhythms are regulated, in part, by release of melatonin from the brain
• Menopause—between 30% and 40% of menopausal women experience insomnia; this may be due to hot flashes, night sweats, anxiety, and/or fluctuations in hormones
• 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; frequently causes heartburn), fibromyalgia or 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 leg syndrome (a sense of indescribable uneasiness, twitching, or restlessness that occurs in the legs after going to bed), post-traumatic stress disorder
• Certain medications—decongestants, bronchodilators, and beta-blockers
• 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
• Stressful or traumatic event
• Night shift or changing work schedule
• Travel across time zones
• Substance abuse
• Asthma—bronchodilators occasionally cause insomnia
• Excessive computer work

Diagnosis

If you report symptoms of insomnia or sleep disorders to your physician, he or she will first obtain a detailed sleep history by asking questions about your sleep patterns and sleep quality. He or she will also ask questions to determine whether you snore, have any underlying medical conditions, take medications, or have recently undergone any significant life changes. Keeping a sleep diary (recording all sleep-related information) may help the physician determine the type of insomnia and how best to treat it. The primary care physician may recommend a sleep specialist or a sleep disorders center where brain waves, body movements, breathing, and heartbeats may be electronically monitored during sleep.

Preventive Care

The following lifestyle changes can help prevent insomnia:

• Exercising regularly—best when done before dinner; exercise can stimulate arousal so should not be done too close to bedtime
• Avoiding caffeine (especially after noon) and nicotine
• Getting regular exposure to late afternoon sun—stimulates release of melatonin which helps 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 Approach

Behavioral techniques are the preferred treatments for people with chronic insomnia. Up to 80% of those with insomnia improve with these approaches, and, unlike many medications for insomnia, behavioral techniques do not carry significant risks and side effects. Studies also indicate that healthy sleep habits are necessary for treating insomnia, regardless of its cause, particularly in combination with mind/body therapies such as stimulus control therapy, bright-light therapy, and cognitive-behavioral therapy. Additionally, acupuncture and acupressure have a long tradition of treating insomnia successfully, particularly in the elderly; the herb, valerian, may be useful for certain individuals. Homeopathic remedies may also improve symptoms in some individuals. Generally, medications by prescription or over-the-counter (OTC) are helpful in promoting sleep, but they are not recommended for insomnia that persists for more than 4 weeks. Long-term use of some medications may cause addiction.

Lifestyle

Studies reveal that healthy sleep habits are essential for treating insomnia. The following healthy sleep habits (in addition to the steps mentioned in the Preventive Care section) may help treat the condition:

• Maintaining a consistent bed and wake time
• Establishing the bedroom as a place for sleep and sexual activity only, not for reading, watching television, or working
• Avoiding naps, especially in the evening
• Taking a hot bath about two hours before bedtime
• Keeping the bedroom cool, well-ventilated, quiet, and dark
• Avoiding looking at the clock; this promotes anxiety and obsession about time
• Avoiding fluids just before bedtime
• Avoiding television just before bedtime
• Eating a carbohydrate snack, such as cereal or crackers, just before bedtime
• If sleep does not occur within 15 to 20 minutes in bed, moving to another room with dim lighting

Medications

Generally, medications may be helpful for short-term insomnia, but they are not recommended for insomnia that persists for more than 4 weeks. These medications include:

• Over-the-counter sleeping pills (such as diphenhydramine)—promote sleep if insomnia occurs only occasionally
• Antidepressants (such as trazodone)—may be prescribed in low doses at night to promote sleep
• Benzodiazepines (such as triazolam and lorazepam)—often very successful for resolving insomnia in the short term; long-term use may have serious side effects including daytime drowsiness, depression, sleep walking, and addiction; must not be used with alcohol
• Non-benzodiazepine short-acting hypnotics (such as zoldipam and zaleplon)—fewer side effects and less likely to cause addiction than benzodiazepines; particularly effective for elderly and depressed people; side effects may include nightmares and headaches; should not be used with alcohol

Nutrition and Dietary Supplements

A carbohydrate snack of cereal or crackers with milk before bed may help because foods rich in carbohydrates and low in protein and fat may boost the production of serotonin and melatonin, brain chemicals thought to promote sleep.

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

L-tryptophan and 5-hydroxytryptophan (5-HTP)
Medical research indicates that supplementation with 1 g L-tryptophan before bedtime can induce sleepiness and delay wake times. L-tryptophan is thought to bring on sleep by raising levels of serotonin, a body chemical that promotes relaxation. This supplement should be used with caution, however, as it may adversely interact with certain anti-depressants (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 on occasion.

Studies also suggest that 5-hydroxytryptophan, made from tryptophan in the body or available in supplement form, may be useful in treating insomnia associated with depression. Like tryptophan, however, reports of EMS have been associated with its use.

Melatonin
Melatonin supplements appear to be most useful for inducing sleep in certain people, particularly those with 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 recent review of scientific studies found that melatonin supplements help prevent jet lag, particularly in people who cross five or more time zones. A few studies suggest that melatonin is significantly more effective than placebo 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 over the long term. More research is needed in this area. Generally, when melatonin is used, 1 to 3 mg of the supplement is recommended for sleep, but as little as 0.3 mg has been used successfully.

Herbs

Valerian (Valeriana officinalis)
Studies have shown that valerian acts as a mild sedative and improves both the ability to fall asleep and the quality of sleep. In one trial, 166 people were randomly assigned to receive valerian extract, an herbal mixture containing valerian, hops (Humulus lupulus), and lemon balm (Melissa officinalis), or placebo. The participants who received either valerian alone or the herbal mixture reported that sleep quality and the ability to fall asleep improved. Other studies have reported similar results. Valerian should not be combined with barbiturates, which currently are rarely prescribed for insomnia. A typical dose of valerian ranges from 150 to 450 mg per day.

Kava kava (Piper methysticum)
Short-term clinical studies suggest that kava kava is effective for insomnia. According to a recent study, kava kava and diazepam (one of the benzodiazepines) induce similar changes in brain wave activity. Although quite rare, kava may cause skin reactions and liver failure (when used at very high doses for a prolonged period). This herb should not be used at the same time as benzodiazepines.

Other herbs that a professional herbalist may use to treat insomnia include:

• Passionflower (Passiflora incarnata)
• Hops (Humulus lupulus)
• Jamaica dogwood (Piscidia erythrina/Piscidia piscipula)
• Lemon balm (Melissa officinalis)
• Lavender flower (Lavandula angustifolia)
• German chamomile (Matricaria recutita)
• Motherwort (Leonarus cardiaca)
• Gotu kola (Centella asiatica)
• Skullcap (Scultellaria lateriflora)

Homeopathy

There have been few studies examining the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for insomnia. based on his or her knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her 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; 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 by way of 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, 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, whose minds are often overactive
• Pulsatilla — for women and children who are particularly emotional and do not like sleeping alone; sleeping in a warm room tends to worsen insomnia and 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 acupuncture may 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. 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.

Chiropractic

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

Massage and Physical Therapy

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, particularly lavender (Lavandula angustifolia), may result in improved sleep quality, more stable mood, increased mental capacity, and reduced anxiety. In one recent study, 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 methods of treatment. These methods include:

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 his or her insomnia.

Stimulus Control Techniques
This technique involves learning to use the bedroom only for sleeping and sexuality. Individuals using this technique learn to go to bed only when tired and leave the bedroom when not asleep. They must also wake up at the same time every day, including weekends and vacations, regardless of the amount of sleep they had.

Sleep Restriction
This method involves improving 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 to 20 minutes until the 85% goal is achieved. Once accomplished, 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 his or her sleep problem. One cognitive-behavioral approach, called paradoxical intention, helps to retrain an individual's fears of sleep by doing the opposite of what is causing the anxiety. For example, a person with insomnia worries long before going to bed about not being able to sleep and the difficulty he or she will have at bedtime. Rather than preparing to go to sleep, therefore, 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 he or she 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, Chinese massage (tui na), and qi gong. Acupuncture is considered to be the most effective.

Other Considerations

Pregnancy

• Insomnia usually occurs in the later months of pregnancy when the mother's size and need to urinate disrupt sleep.
• Benzodiazepines should be avoided during pregnancy and while breastfeeding.

Warnings and Precautions

• Alcohol should be avoided in those who are taking prescription medications or OTC sleeping pills
• Discontinuing prescription medications or OTC sleeping pills can lead to rebound insomnia

Prognosis and Complications

Most people who have insomnia with no underlying medical conditions tend to 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.

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