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Insomnia
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Insomnia is a symptom of a sleeping disorder characterized by persistent difficulty falling asleep or staying asleep despite the opportunity. Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is "difficulty initiating or maintaining sleep, or both" and it may be due to inadequate quality or quantity of sleep. It is typically followed by functional impairment while awake.
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Insomnia is a symptom of a sleeping disorder characterized by persistent difficulty falling asleep or staying asleep despite the opportunity. Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is "difficulty initiating or maintaining sleep, or both" and it may be due to inadequate quality or quantity of sleep. It is typically followed by functional impairment while awake. Insomniacs have been known to complain about being unable to close their eyes or "rest their
mind" for more than a few minutes at a time. Both organic and non-organic insomnia constitute a sleep disorder.
According to the U.S. Department of Health and Human Services in year 2007, approximately 64 million Americans suffer from insomnia on a regular basis each year. Insomnia occurs 1.4 times more commonly in women than in men.
Types of insomnia
Although there are several different degrees of insomnia, three types of insomnia have been clearly identified: transient, acute, and chronic.
- Transient insomnia lasts from days to weeks. 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 between three weeks to six months.
- Chronic insomnia lasts for years at a time. It can be caused by another disorder, or it can be a primary disorder. Its effects can vary according to its causes. They might include sleepiness, muscular fatigue, hallucinations, and/or mental fatigue; but people with chronic insomnia often show increased alertness. Some people that live with this disorder see things as though they were happening in slow motion, whereas moving objects seem to blend together. Can cause double vision.
Patterns of insomnia
The pattern of insomnia often is related to the etiology.
- Onset insomnia - difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
- Middle-of-the-Night Insomnia - Insomnia characterized by difficulty returning to sleep after awakening in the middle of the night or waking too early in the morning. Also referred to as nocturnal awakenings. Encompasses middle and terminal insomnia.
- Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with pain disorders or medical illness.
- Terminal (or late) insomnia - early morning waking. Characteristic of clinical depression.
Causes
Insomnia can be caused by:
- Psychoactive drugs or stimulants, including certain medications, herbs, caffeine, cocaine, ephedrine, amphetamines, methylphenidate, MDMA, methamphetamine and modafinil
- Fluoroquinolone antibiotic drugs, see Fluoroquinolone toxicity, associated with more severe and chronic types of insomnia
- Hormone shifts such as those that precede menstruation and those during menopause
- Life problems like fear, stress, anxiety, emotional or mental tension, work problems, financial stress, unsatisfactory sex life
- Mental disorders such as bipolar disorder, clinical depression, general anxiety disorder, post traumatic stress disorder, schizophrenia, or obsessive compulsive disorder.
- Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Jet lag is seen in people who travel through multiple time zones, as the time relative to the rising and setting of the sun no longer coincides with the body's internal concept of it. The insomnia experienced by shift workers is also a circadian rhythm sleep disorder.
- Estrogen is considered to play a significant role in women’s mental health (including insomnia). A conceptual model of how estrogen affects mood was suggested by Douma et al 2005 based on their extensive literature review relating activity of endogenous, bio-identical and synthetic estrogen with mood and well-being. They concluded the sudden estrogen withdrawal, fluctuating estrogen, and periods of sustained estrogen low levels correlated with significant mood lowering. Clinical recovery from depression postpartum, perimenopause, and postmenopause was shown to be effective after levels of estrogen were stabilized and/or restored.
- Certain neurological disorders, brain lesions, or a history of traumatic brain injury
- Medical conditions such as hyperthyroidism
- Abuse of over-the counter or prescription sleep aids can produce rebound insomnia
- Poor sleep hygiene, e.g., noise
- Parasomnia, which includes a number of disruptive sleep events including nightmares, sleepwalking, violent behavior while sleeping, and REM behavior disorder, in which a person moves his/her physical body in response to events within his/her dreams
- A rare genetic condition can cause a prion-based, permanent and eventually fatal form of insomnia called fatal familial insomnia
- Parasites can cause intestinal disturbances while sleeping.
A common misperception is that the amount of sleep a person requires decreases as he or she ages. The ability to sleep for long periods, rather than the need for sleep, appears to be lost as people get older. Some elderly insomniacs toss and turn in bed and occasionally fall off the bed at night, diminishing the amount of sleep they receive.
An overactive mind or physical pain may also be causes. Finding the underlying cause of insomnia is usually necessary to cure it. Insomnia can be common after the loss of a loved one, even years or decades after the death, if they have not gone through the grieving process. Overall, symptoms and the degree of their severity affect each individual differently depending on their mental health, physical condition, and attitude or personality.
Epidemiology
The National Sleep Foundation's 2002 Sleep in America poll showed that 58% of adults in the U.S. experienced symptoms of insomnia a few nights a week or more. Although insomnia was the most common sleep problem among about one half of older adults (48%), they were less likely to experience frequent symptoms of insomnia than their younger counterparts (45% vs. 62%), and their symptoms were more likely to be associated with medical conditions, according to the 2003 poll of adults between the ages of 55 and 84.
Diagnosis
Specialists in sleep medicine are qualified to diagnose the many different sleep disorders. Patients with various disorders including delayed sleep phase syndrome are often mis-diagnosed with insomnia. If a patient has trouble getting to sleep, but has normal sleep architecture once asleep, a circadian rhythm disorder is a likely cause.
Insomnia versus poor sleep quality
Poor sleep quality can occur as a result of sleep apnea or clinical depression. Poor sleep quality is caused by the individual not reaching stage 4 or delta sleep which has restorative properties. There are, however, people who are unable to achieve stage 4 sleep due to brain damage who lead perfectly normal lives.
Sleep apnea is a condition that occurs when a sleeping person's breathing is interrupted, thus interrupting the normal sleep cycle. With the obstructive form of the condition, some part of the sleeper's respiratory tract loses muscle tone and partially collapses. People with obstructive sleep apnea often do not remember awakening or having difficulty breathing, but they complain of excessive sleepiness during the day. Central sleep apnea interrupts the normal breathing stimulus of the central nervous system, and the individual must actually wake up to resume breathing. This form of apnea is often related to a cerebral vascular condition, congestive heart failure, and premature aging.
Major depression leads to alterations in the function of the hypothalamic-pituitary-adrenal axis, causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.
Treatment for insomnia
In many cases, insomnia is caused by another disease, side effects from medications or a psychological problem. It is important to identify or rule out medical and psychological before deciding on the treatment for the insomnia. Attention to sleep hygiene is an important first line treatment strategy and should be tried before any pharmacological approach is considered.
Non-pharmacological strategies
Non-pharmacological strategies are superior to hypnotic medication for insomnia because tolerance develops to the hypnotic effects as well as dependence can develop with rebound withdrawal effects developing upon discontinuation. Hypnotic medication is therefore only recommended for short term use. Non pharmacological strategies however, have long lasting improvements to insomnia and are recommended as a first line and long term strategie of managing insomnia. The strategies include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, patient education and relaxation therapy.
Cognitive behavior therapy
A recent study found that cognitive behavior therapy is more effective than hypnotic medications in controlling insomnia. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Hypnotic medications are equally effective in the short term treatment of insomnia but their effects wear off over time due to tolerance. The effects of cognitive behavior therapy have sustained and lasting effects on treating insomnia long after therapy has been discontinued. The addition of hypnotic medications with CBT adds no benefit in insomnia. The long lasting benefits of a course of CBT shows superiority over pharmacological hypnotic drugs. Even in the short term when compared to short term hypnotic medication such as zolpidem (Ambien), CBT still shows significant superiority. Thus CBT is recommended as a first line treatment for insomnia.
Medications
Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down. The benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of side effects such as day time fatigue, motor vehicle crashes, cognitive impairments and falls and fractures. Elderly people are more sensitive to these side effects.
In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was not significantly more than for antidepressants. Benzodiazepines did not have a significant tendency for more adverse drug reactions. Chronic users of hypnotic medications for insomnia do not have better sleep than chronic insomniacs who do not take medications. In fact, chronic users of hypnotic medications actually have more regular nighttime awakenings than insomniacs who do not take hypnotic medications. Thus short term or occasional use of hypnotics can be benefitial but long term use may be detrimental to sleep.
Benzodiazepines
The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABAA receptor. These include drugs such as temazepam, flunitrazepam, triazolam, flurazepam, midazolam, nitrazepam and quazepam. These drugs can lead to tolerance, physical dependence and the benzodiazepine withdrawal syndrome upon discontinuation, especially after consistent usage over long periods of time. Benzodiazepines while inducing unconsciousness, actually worsen sleep as they promote light sleep whilst decreasing time spent in deep sleep such as REM sleep. A further problem is with regular use of short acting sleep aids for insomnia, day time rebound anxiety can emerge.
Non-benzodiazepines
Nonbenzodiazepine sedative-hypnotic drugs, such as Ambien (zolpidem), Sonata (zaleplon), Imovane (zopiclone) and Lunesta (eszopiclone), are a newer classification of hypnotic medications. They work on the benzodiazepine site on the GABAA receptor complex similarly to the benzodiazepine class of drugs. Some but not all of the nonbenzodiazepines are selective for the a1 subunit on GABAA receptors which is responsible for inducing sleep and may therefore have a cleaner side effect profile than the older benzodiazepines. Zopiclone and eszopiclone like benzodiazepine drugs bind unselectively to a1, a2, a3 and a5 GABAA benzodiazepine receptors. Zolpidem is more selective and zaleplon is highly selective for the a1 subunit thus giving them an advantage over benzodiazepines in terms of sleep architecture and a reduction in side effects. However, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence though less than traditional benzodiazepines and can also cause the same memory and cognitive disturbances along with morning sedation.
Antidepressants
Some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can often have a very strong sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture. As with many benzodiazepines, the use of antidepressants in the treatment of insomnia can lead to physical dependence; withdrawal may induce rebound insomnia and actually further complicate matters in the long-term.
Mirtazapine is known to decrease sleep latency, promoting sleep effiency and increasing the total amount of sleeping time in patients suffering from both depression and insomnia
Melatonin
The hormone and supplement melatonin is effective in several types of insomnia. Melatonin has demonstrated effectiveness equivalent to the prescription sleeping tablet zopiclone in inducing sleep and regulating the sleep/waking cycle. One particular benefit of melatonin is that it can treat insomnia without altering the sleep architecture which is altered by many prescription sleeping tablets. Another benefit is it does not impair performance related skills. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation. Natural substances such as 5-HTP and L-Tryptophan have been said to fortify the serotonin-melatonin pathway and aid people with various sleep disorders including insomnia.
Antihistamines
The antihistamine Benadryl (diphenhydramine) is widely used in nonprescription sleep aids such as Tylenol PM, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.
Periactin (Cyproheptadine) is a useful alternative to benzodiazepine hypnotics in the treatment of insomnia. Cyproheptadine may be superior to benzodiazepines in the treatment of insomnia because cyproheptadine enhances sleep quality and quantity whereas benzodiazepines tend to decrease sleep quality.
Atypical Antipsychotics
Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia. Over time, Seroquel may lose its effectiveness as a sedative. The ability of Seroquel to produce sedation is determined by the dosage. Higher doses (300 mg - 900 mg) are usually taken for its use as an antipsychotic, while lower doses (25 mg - 200 mg) have a marked sedative effect, e.g. if a patient takes 300 mg, he/she will more likely benefit from the drug's antipsychotic effects, but if the dose is brought down to 100 mg, it will leave the patient feeling more sedated than at 300 mg, because it primarily works as a sedative at lower doses.
Other Substances
Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective. Cannabis has also been proven as an effective treatment for insomnia.
Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.
Insomnia may be a symptom of magnesium deficiency, or low magnesium levels, but this has not yet been proven. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.
Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal.
Complementary and alternative medicine
Some traditional and anecdotal remedies for insomnia include: drinking warm milk before bedtime, taking a warm bath, exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, going to bed at a reasonable hour and getting up early, and avoiding exposing the eyes to too much light, especially blue light, a few hours before bedtime. Initial treatment of insomnia may include the rules of sleep hygiene.
The herb valerian can be effective and a useful alternative to benzodiazepines in alleviating insomnia due to its pharmacological activity on the GABAA receptor complex.
Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness.
Many believe that listening to slow paced music will help insomniacs fall asleep.
The more relaxed a person is, the greater the likelihood of getting a good night's sleep. Relaxation techniques such as meditation have been shown to help people sleep. One deep breathing technique involves synchronizing breath to a blue light.
Tai Chi helps improve sleep. At UCLA a controlled study found that the Tai Chi group, practicing two hours of Tai Chi per week, left 63% of the Tai Chi group with improved quality of sleep. The control group practicing only healthy habits, but no Tai Chi practice, left only 32% with improved quality of sleep. Tai chi alone doubled people's chances of improved sleep patterns, over simply adopting healthy habits.
In another study, reported in The Journal of the American Geriatric Society, 5, 892-900, Tai chi participants reported sleep-onset latency of about 18 minutes less per night and sleep duration of about 48 minutes more per night than low-impact exercise participants.
Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, herbology and other techniques, with the goal of resolving the problem at a subtle level.
In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or metta. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the Metta (Mettanisamsa) Sutta, Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.
Hypnotherapy, self hypnosis and guided imagery can be effective in not only falling asleep and staying asleep; they can also help to develop good sleeping habits over time. Visualizing can be effective in taking the mind away from present day anxieties and towards a more relaxing place. Binaural beats can help people fall asleep faster using special sounds.
See also
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