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Insomnia

Insomnia

Definition

Insomnia is the inability to obtain an adequate amount or quality of sleep. The difficulty can be in falling asleep, remaining asleep, or both. People with insomnia do not feel refreshed when they wake up. Insomnia is a common symptom affecting millions of people that may be caused by many conditions, diseases, or circumstances.

According to a 1999 American Medical Association (AMA) report, approximately 30% of adults in the United States suffer occasionally from insomnia and 10% experience chronic insomnia.

Description

Sleep is essential for mental and physical restoration. It is a cycle with two separate states: rapid eye movement (REM), the stage in which most dreaming occurs; and non-REM (NREM). Four stages of sleep take place during NREM: stage I, when the person passes from relaxed wakefulness; stage II, an early stage of light sleep; stages III and IV, which are increasing degrees of deep sleep. Most stage IV sleep (also called delta sleep), occurs in the first several hours of sleep. A period of REM sleep normally follows a period of NREM sleep.

Sleeplessness or insomnia is a symptom and may be caused by "stress, anxiety, depression , disease, pain , medications, sleep disorders, poor sleep habits .. [and] sleep environment and health habits," according to the National Sleep Foundation (NSF).

Women are 1.3 times more likely to report insomnia than men, according to the NSF. Women may experience sleeplessness before and at the onset of the menstrual cycle, during pregnancy , and menopause . The foundation reported that people over the age of 65 are "more likely to complain of insomnia than younger people." Furthermore, people who are divorced, widowed, or separated are more likely to have the problem than those who are married. In addition, insomnia is more frequently reported by those with lower socioeconomic status.

Insomnia is classified both by its nightly symptoms and its duration. Sleep-onset insomnia refers to difficulty falling asleep. Maintenance insomnia refers to waking frequently during the night or waking early. Insomnia is also classified in relation to the number of sleepless nights. Short-term or transient insomnia is a common occurrence and usually lasts only a few days. Long-term or chronic insomnia lasts more than three weeks and increases the risk for injuries in the home, at the workplace, and while driving because of daytime sleepiness and decreased concentration. Chronic insomnia can also lead to mood disorders like depression.

Insomnia comes with a high price tag for the nation. NSF in 1999 reported that an estimated $14 billion was spent in one year on such direct costs as insomnia treatment, healthcare services, and hospital and nursing home care. Annual indirect costs like work loss, property damage from accidents, and transportation to and from health care providers were estimated at close to $28 billion. Furthermore, insomnia accounted for $18 billion in lost productivity, according to a 1997 National Sleep Foundation survey.

Causes & symptoms

Transient insomnia is often caused by a temporary situation in a person's life, such as an argument with a loved one, a brief medical illness, or jet lag . When the situation is resolved or the precipitating factor disappears, the condition goes away, usually without medical treatment.

Such prescription drugs as asthma medicine, steroids, and anti-depressants can cause insomnia. Sleeplessness may also be a side effect of over-the-counter products like nasal decongestants and appetite suppressants.

Chronic insomnia usually has different causes, and there may be more than one. These include:

  • A medical condition or its treatment, including sleep apnea, arthritis, a heart condition, and asthma.
  • Use of such substances as caffeine , alcohol, and nicotine.
  • Psychiatric conditions like mood or anxiety disorders.
  • Stress or depression, such as sadness caused by the loss of a loved one or a job.
  • Disturbed sleep cycles caused by a change in work shift.
  • Sleep-disordered breathing, such as snoring.
  • Periodic jerky leg movements, nocturnal myoclonus, which happen just as the individual is falling asleep.
  • Repeated nightmares or panic attacks during sleep.

Another cause is excessive worrying about whether or not a person will be able to fall asleep, which creates so much anxiety that the individual's bedtime rituals and behavior actually trigger insomnia. This is called psychophysiological insomnia.

Symptoms of insomnia

People who have insomnia do not start the day refreshed from a good night's sleep. They are tired. They may have difficulty falling asleep, and commonly lie in bed tossing and turning for hours. Or the individual may go to sleep without a problem but wakes in the early hours of the morning and is either unable to go back to sleep, or drifts into a restless, unsatisfying sleep. This is a common symptom in the elderly and those suffering from depression. Sometimes sleep patterns are reversed and the individual has difficulty staying awake during the day and takes frequent naps. The sleep at night is fitful and frequently interrupted.

Diagnosis

Insomnia, unlike some medical conditions, is easily recognizable. People know when they aren't getting enough sleep. The key to treating insomnia is determining its causes. Some people can identify sleep-inhibiting factors such as a death in the family or a hectic work schedule with too much caffeine consumption and not enough exercise . A doctor will take factors such as these into account when making a diagnosis.

The physician's diagnosis is based on the patient's reported signs and symptoms. The doctor may review a patient's health history or order tests to determine if a medical condition is causing the insomnia. The physician may ask if the patient is depressed, in pain, under stress, or taking medications, according to the National Sleep Foundation. The doctor may ask about disruptions in a patient's life such as working nontraditional shifts or traveling across different time zones.

It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, caffeine, nicotine, medications, exercise, and any other information recommended by the physician. If the patient has a bed partner, information can be obtained about whether the patient snores or is restless during sleep. This record, together with a medical history and physical examination, can help confirm the doctor's assessment.

A wide variety of healthcare professionals can recognize and treat insomnia, but when a patient with chronic insomnia does not respond to treatment, or the condition is not adequately explained by the patient's physical, emotional, or mental circumstances, then more extensive testing by a specialist in sleep disorders may be warranted.

Treatment

In both alternative and conventional medicine, treatment of insomnia includes alleviating or coping with any physical and emotional problems that contribute to the condition. Also effective is exploration of changes in lifestyle that will improve the situation.

Changes in behavior

Patients can make changes in their daily routine that are simple and effective in treating insomnia. Eating a healthy diet rich in calcium, magnesium , and the B vitamins is also beneficial. A high protein snack like yogurt before going to bed is recommended.

Patients should go to bed only when sleepy and use the bedroom only for sleep. Activities like reading, watching television, or snacking should take place elsewhere. If people are unable to go to sleep, they should go into another room and do something like reading. People should return to bed only when sleepy. Patients should set the alarm and get up every morning at the same time, no matter how much they have slept, to establish a regular sleepwake pattern. Naps during the day should be avoided, but if absolutely necessary, than a 30-minute nap early in the afternoon may not interfere with sleep at night.

Another successful technique is called sleep-restriction therapy, restricting the time in bed to the actual time spent sleeping. This approach allows a slight sleep debt to build up, which increases the individual's ability to fall asleep and stay asleep. If a patient sleeps five hours a night, the time in bed is limited to 55.5 hours. The time in bed is gradually increased in small segments, with the individual rising at the same time each morning; at least 85% of the time in bed must be spent sleeping.

Mind and body relaxation

Incorporating relaxation techniques into bedtime rituals helps a person go to sleep faster and improves the quality of sleep. These, alone or in combination with other relaxation techniques, can safely promote sleepiness. Also effective are massage techniques such as the "cat stroke." The masseuse's hands move gently across the back. Four other types of stress-reducing bodywork were recommended in Spontaneous Healing, the book by Andrew Weil , M.D., who practices natural and preventative medicine. Weil recommended Feldenkrais, which includes movements, floor exercises, and body work; Rolfing , which involves firm pressure; shiatsu, the traditional Japanese form of body work; and Trager work.

Learning to substitute pleasant thoughts for unpleasant ones (imagery training) helps reduce worrying. Another technique is using audiotapes that combine the sounds of nature with soft relaxing music. Meditation, prayer, and breathing exercises can also be effective.

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Much treatment is centered around herbal remedies. The herbs most often recommended for treating insomnia include reishi mushroom, hops, valerian, skullcap , passion flower, lemon balm , ginseng, St. John's wort, and kava, which is also known as kava kava . Herbs are "generally safe," but they have not been tested or classified in the United States by the U.S. Food and Drug Administration (FDA).

Herbal teas

Some people treat insomnia by sipping a warm cup of tea made with an herb such as chamomile , hops, passionflower, or St. John's wort.

Aromatherapy and hydrotherapy

Aromatherapy involves healing through essential oils , the aromatic extracts of plants. Essential oils may be used for a soothing bath; applied to the face, neck, shoulders, and pillow; or diffused in air.

Hydrotherapy consists of a warm bath, scented with an essence such as rose, lavender , marjoram, or chamomile. In the 1998 book Healing Anxiety with Herbs, Harold Bloomfield, m.d., recommended adding 2-15 drops of 10% essential oils into approximately 100°F (38° C) water . He also recommended using lavender and also suggested using ylang-ylang, neroli (orange blossom), geranium, and patchouli. The bath should be "approached in an unhurried and meditative state," Bloomfield wrote.

Dream pillows

Another form of aromatherapy involves sleeping on a dream pillow. Also known as a sleep pillow, it can be made by sewing together two 8-inch pieces of fabric. There should be an opening wide enough to insert a tablespoon. Herbs such as hops, chamomile, and lavender are spooned into the dream pillow, which is placed under the bed pillow.

Melatonin

Melatonin is a natural hormone that is secreted from the brain's pineal gland. The gland regulates a person's biological clock, particularly day and night cycles. When taken as a 3-mg dose one to two hours before bed for a maximum of four to five days per week, the dietary supplement melatonin is said to be effective in shortening the time before one falls asleep. The hormone can help to avoid jet lag and to establish sleep patterns for shift workers. However, melatonin is not regulated by the FDA, so there are no regulatory controls. Side effects may include mental impairment, drowsiness, severe headaches, and nightmares.

Traditional Chinese medicine

Traditional Chinese medicine (TCM) treatments for insomnia include acupuncture and herbal remedies. Acupuncture involves the insertion of needles to manipulate energy flows around the body. Acupuncture is also applied to the treatment of conditions including anxiety.

In TCM, herbs are used as remedies in teas and other preparations. Treatments for insomnia include reishi, a medicinal mushroom available in extract form.

Light therapy

In light therapy , natural or artificial light is used to boost serotonin, a neurotransmitter in the brain related to reducing anxiety. This therapy is used to treat seasonal affective disorder, a condition that some people experience when there is less sunlight or fewer daylight hours. Bright light therapy can be used for people whose insomnia is caused by jet lag or irregular work shifts. In the morning, the person is exposed to artificial lamps with a brightness of more than 2,000 lux. The treatment continues with avoidance of bright light during the evening.

Allopathic treatment

A physician may determine that drug therapy is necessary to treat insomnia. Drugs may be prescribed if the patient is undergoing a crisis or insomnia persists after a patient has made lifestyle changes. However, drug therapy is regarded as a short-term remedy, not a solution.

Conventional medications given for insomnia include sedatives, tranquilizers, and antianxiety drugs. All require a doctor's prescription and may become habit-forming. They can lose effectiveness over time and can reduce alertness during the day. The medications should be taken up to four times daily or as directed for approximately three to four weeks. This will vary with the physician, patient, and medication. If insomnia is related to depression, then an antidepressant medication may be helpful.

Drugs prescribed for improving sleep are called hypnotics. This category includes benzodiazepines, which are prescribed for anxiety and insomnia. Benzodiazepines most commonly prescribed for insomnia include Dalmane (fluazepam), Halcion (triazolam), Ativan (lorazepam), Xanax (alprazolam), Restoril (tempazepam), and Serax (oxazepam).

Insomnia is such a widespread problem that "people buy more over-the-counter and prescription sleeping medications than any other drug," according to CBS Health Watch. Many over-the-counter drugs have antihistamines as an active ingredient. While these products are not addictive, some experts believe they are not very effective in sustaining stage IV sleep and can affect the quality of sleep.

Over-the-counter sleep products include Nytol, Sleep-Eez, and Sominex. Antihistamines are used in combination with pain relievers in products including Anacin PM, Excedrin PM, Tylenol PM, Unison, and Quiet World.

Expected results

Insomnia has numerous causes and treatments, so the amount of time may vary before results are seen. A prescription drug may bring immediate results to someone coping with a spouse's death. An herbal remedy may not work immediately for a person who consumed excessive amounts of caffeine to stay awake at work after a sleepless night.

There has been research that provides information about when some treatments take effect:

  • Melatonin: a dose of 3-5 mg taken within an hour of retiring will normalize sleep within 1-2 weeks.
  • A combination of hops and valerian at bedtime can provide a good night's sleep.
  • A combination of alternative therapies should bring a difference in disturbed sleep within two to four days.
  • Valerian extract may take from two to three weeks before "significant benefits" are seen.
  • St. John's wort can take two weeks to take effect.
  • Combinations of treatments could more quickly bring about an uninterrupted night of sleep. The person who reduces caffeine intake, walks for 15 minutes and enjoys an herbal bath may discover that that combination brings restful sleep.
  • Acupuncture: "A state of deep relaxation is often an immediate benefit of treatment for chronically anxious patients," William Collinge wrote in The American Holistic Health Association Complete Guide to Alternative Medicine. In addition, positive results were recorded in a study of people who had trouble falling asleep or remaining asleep, according to the an article in the October 1999 issue of the Alternative Medicine Newsletter. Patients received acupuncture for three to five sessions at weekly intervals. While acupuncture appeared effective, a "directive influence by the therapist cannot be excluded," according to the article.
  • Light therapy usually results in earlier bedtimes.

Prevention

Prevention of insomnia centers around promotion of a healthy lifestyle. A balance of rest, recreation, and exercise in combination with stress management, regular physical examinations, and a healthy diet can do much to reduce the risk.

Walking is also recommended. However, exercise should be done no more than three hours before bedtime.

Drinks that contain caffeine such as coffee, tea and colas, chocolate (which contains a stimulant), and alcohol, which initially makes a person sleepy but a few hours later can have the opposite effect should all be avoided.

Maintaining a comfortable bedroom temperature, reducing noise, and eliminating light are also helpful.

Watching television should be avoided because it has an arousing effect. Weil wrote that the news with its "murder, mayhem, and misery" is a major source of turmoil. He sometimes advises "news fasts" as part of a healing program.

Exercise, relaxation, and nutrition should be considered ongoing preventive measures. While life will bring unexpected stresses and pressures, the person who is familiar with relaxation techniques will be more prepared to cope with insomnia.

Resources

BOOKS

Albright, Peter. The Complete Book of Complementary Therapies. Allentown, PA: People's Medical Society, 1997.

Bloomfield, Harold. Healing Anxiety with Herbs. New York: HarperCollins, 1998.

Boyd, Mary Ann, and Mary Ann Nihart. Psychiatric Nursing: Contemporary Practice. Philadelphia, PA: Lippincott, 1998.

Bruce, Debra Fulghum and Harris H. McIlwain, The Unofficial Guide to Alternative Medicine. New York: Macmillan General Reference, 1998.

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1999.

Collinge, William. The American Holistic Health Association Complete Guide to Alternative Medicine. New York: Warner Books, 1996.

Frisch, Noreen Cavan, and Lawrence E. Frisch. Psychiatric Mental Health Nursing. Albany, NY: Delmar, 1988.

Keville, Kathi. Herbs for Health and Healing. Emmaus, PA: Rodale Press, Inc., 1996.

Nash, Barbara. From Acupuncture to Zen: an encyclopedia of natural therapies. Alameda, CA: Hunter House, 1996.

Ullman, Dana. The Consumer's Guide to Homeopathy. New York: G.P. Putnam Books, 1995.

Weil, Andrew. Spontaneous Healing. New York: Random House, 1995.

ORGANIZATIONS

American Sleep Disorders Association. 6301 Bandel Road, Suite 101, Rochester, MN 55901. <http://www.asda.org>.

National Sleep Foundation. 1522 K St. NW, Suite 510, Washington, DC 20005. <http://www.sleepfoundation.org>.

OTHER

"Acupuncture and Insomnia." Alternative Medicine Update (October 1999). <http://www.healthmall.com>.

"Insomnia." CBS Health Watch. <http://www.cbshealthwatch.com>.

"Patient Information: Insomnia and What You Can Do to Sleep Better." American Family Physician. 49, no. 6 (May 1, 1994). <http://srvr.third-wave.com/tricounty/insomnia.html> (1998).

"Sleep Aids: Everything You Wanted to KnowBut Were Too Tired to Ask." National Sleep Foundation, 1999. <http://www.sleepfoundation.org/publications/sleepaids.html>.

"What to Do When You Can't Sleep." Children's Hospital of Iowa. 1995. <http://www.vh.org/Patients/IHB/FamilyPractice/AFP/January1995/Insomnia.html> (1998).

Willard, Terry. "Insomnia: Wake up to ten simple solutions." Herbs for Health. HealthWorld Online. <http://www.healthy.net/hfh/articlesHFH/sleep.htm>.

Liz Swain

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Insomnia

Insomnia

Definition

Insomnia is a condition that occurs when a person in unable to get long enough or refreshing enough sleep at night. Insomnia can result from an inability to fall asleep, an inability to stay asleep, or waking too early before having gotten enough sleep.

Description

Insomnia is a disorder in which people are unable to get enough, or enough restorative, sleep because of one or more factors. People with insomnia often have daytime symptoms related to a lack of sleep, such as daytime sleepiness, fatigue , and decreased mental clarity.

There are two main types of insomnia. One is acute insomnia (sometimes called transient insomnia). This type occurs when insomnia symptoms exist over a reasonably short period of time. The other type is chronic insomnia, which is diagnosed when the symptoms manifest themselves over a longer period (generally more than one month). Insomnia can also be classified as either primary or secondary. Primary insomnia is a disorder that cannot be attributed to another condition or disorder. Secondary insomnia can be traced back to a source, which may be a medical condition; the use of medications, alcohol, or other substances; or a mental disorder such as severe depression.

Not all disruptions in the normal pattern of sleeping and waking are considered insomnia. Such factors as jet lag, unusually high levels of stress , changing work shifts, or other drastic changes in the person's routine can all lead to sleep problems. Unless the problems are ongoing and severe enough that they are causing distress for the person in important areas of life, he or she is not considered to have insomnia.

Causes and symptoms

The symptoms of insomnia can vary greatly from person to person. Some people find that they have trouble falling asleep at night and can lie in bed for hours without being able to drift off. Others find that they fall asleep easily but wake many times during the night. Other people awaken too early in the morning and are then unable to get back to sleep. Some people even get enough hours of sleep but find that they do not feel rested, often because their sleep is too light.

Not all people experiencing insomnia have symptoms that occur during the daytime, but many do. Some people experience such symptoms as reduced ability to concentrate or pay attention, decreased alertness, and mental sluggishness. Some people have trouble staying awake. More people think that they have this symptom than actually do. Upon clinical examination many people who think that they are excessively sleepy during the day actually are not.

Many different things are thought to cause or contribute to insomnia. Such stressors as starting a new job or changes in routine, such as beginning to work a different shift, can lead to temporary sleep problems. Sleep problems can become aggravated, and persist after the worry or change causing the sleep problem has been resolved. This persistence is thought to be related to the anxiety created by attempting to go to sleep and not expecting to fall asleep. Anxiety about sleep loss can lead to a vicious circle in which the person has more and more concern about being able to fall asleep, making it ever increasingly difficult to do so. Some people even report that they are better able to fall asleep when they are not in their beds. This relative success is thought to occur because the new environment is not associated with the fear and anxiety of not being able to sleep, therefore making it easier to fall asleep.

Many other factors are thought to lead to or perpetuate insomnia. These include drinking tea or coffee, eating a large meal, taking certain medications or drugs of abuse (cocaine, amphetamines ) that have a stimulating effect, or exercising heavily in the hours before attempting to sleep. Also, attempting to sleep in a room with too much light or noise can make it harder for some people to sleep. Doing activities in bed that are not associated with sleep, such as reading or watching television, can make it more difficult for some people to fall asleep when they finally want to. Sleep may be even more difficult if the television show or book was frightening or upsetting.

Demographics

There are many different opinions about how much of the general American population experiences insomnia. Estimates suggest that around 520% of the adult population suffers from some form of insomnia or long-term sleeping problems. Nearly half report at least occasional sleeping problems. Accurate data is difficult to gather, as many people misperceive how much sleep they actually get and how many times they normally wake up during the night. It is generally agreed, however, that women are more likely than men to suffer from insomnia. As people get older, they are also are more likely to experience insomnia. People who are nervous or tense are more likely to have insomnia than those who are not. Lastly, people who live near airports or other sources of nighttime as well as daytime noise have higher rates of insomnia than the general population.

Diagnosis

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR ), which presents the guidelines used by the American Psychiatric Association for diagnosis of disorders, in order to be diagnosed with primary insomnia, a person must experience the symptoms for at least a month, and the symptoms must cause them distress or reduce their ability to function successfully. The symptoms cannot be caused by a different sleep disorder, a medical condition, or be a side effect of medications or substance abuse.

Insomnia may also be comorbid with (occur together with) other psychiatric disorders, including mania, depression, and the anxiety disorders.

Insomnia is a disorder that is usually self-reported; that is, patients usually bring up the subject of sleep problems with their doctors rather than the doctor suggesting the diagnosis. There are no laboratory tests for insomnia, but the doctor may suggest keeping a sleep diary, in which the patient notes the time they went to bed, the time(s) at which they got up during the night, their activities before bed, etc. Sleep diaries can be helpful in uncovering specific factors related to the insomnia.

Treatments

Many treatments have been explored for treating insomnia, in a number of different settings. The patient may wish to consider consulting a sleep clinic or a doctor who specializes in the treatment of sleep disorders as well as their family doctor.

Behavioral and educational therapies are usually tried first, because they do not have side effects and cannot create a chemical dependence the way some sleep medications can. Many different approaches have been designed to help patients whose insomnia is linked to particular factors.

Behavioral treatments

One common behavioral therapy involves changing any pre-bedtime activities or behaviors that might interfere with sleep. Avoiding large meals, alcohol or caffeinated beverages, or intensive exercise in the hours before bedtime may help the patient to fall asleep.

Another non-medicinal treatment for insomnia involves controlling the patient's mental associations with the bedroom. The patient is trained to associate the bed only with sleep, not with the frustration of trying to fall asleep or with such waking activities as reading or watching television. As part of this training, if the patient cannot sleep after a certain amount of time, he or she is instructed to get out of bed and spend time somewhere else in the house doing an activity that they find relaxing. The patient lies down again only when sleepy. This technique helps to prevent frustration from trying to sleep.

Another common technique that does not involve medication is sleep restriction therapy. During this therapy, the amount of time that patients are allowed to spend in bed is limited to only slightly more time than they believe that they already sleep at night. Gradually the amount of time patients are allowed to spend in bed is increased until they are getting a full night's sleep. Unfortunately, many people find this treatment difficult to stick with, because they often become mildly sleep-deprived. The resultant fatigue can be useful, however, as it may help them fall asleep more easily and to stay asleep longer at night.

Teaching relaxation and the ability to concentrate on relaxing thoughts or images can also help patients experiencing insomnia. Most of these therapies also include setting times for waking and having the patient stick to them even if he or she has not gotten a full night of sleep. The elimination of all daytime napping can help to facilitate sleep at night. These treatments are effective by themselves but may also be combined with other approaches. The course of treatment depends on the patient's specific symptoms.

Treatment with medications

Many different medicines, which are called hypnotics, are used to treat insomnia. These are usually not recommended for use for longer than a week because they may cause dependence. In addition, there is always the risk of side effects. There are many different types of hypnotics, and choosing one for a patient depends on the patient's symptoms, other drugs that he or she may be taking, any medical or psychological conditions, and other health factors. Medication treatment is best used in coordination with a behavioral therapy program.

Alternative remedies

Alternative remedies for insomnia, particularly herbal preparations, should be mentioned because they are among the most popular nonprescription treatments for sleep problems. According to Prevention magazine, insomnia is the sixth most common condition treated with herbal formulas in the United States; it accounts for 18% of all use of herbal preparations. Some herbs used for insomnia are safer than others. Persons who are using alternative remedies, whether to treat insomnia or other conditions, should always tell their doctor what they are taking, how much, and how often. This warning is important because some herbal preparations that are safe in themselves can interact with prescription medications.

Prognosis

Untreated insomnia has potentially serious consequences, including an increased risk of motor vehicle accidents, impaired school or job performance, and a high rate of absenteeism from work. Fortunately, insomnia can be treated very effectively in most patients. Treatment using a combination of approaches is usually most effective. Patients who have had insomnia once are at an increased risk for recurrent insomnia.

See also Caffeine and related disorders; Chamomile; Passionflower; Valerian

Resources

BOOKS

Aldrich, Michael S. Sleep Medicine. New York: Oxford University Press, 1999.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Insomnia." New York: Simon and Schuster, 2002.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry, 7th edition, Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Long, Scott F. "Preventing and Treating Insomnia" Drug Topics 144, no. 13 (July 3, 2000): 49.

Phillips, Grant T., Jeremy Holdsworth, Scott Cook. "How useful is cognitive behavioral therapy (CBT) for the treatment of chronic insomnia?" Journal of Family Practice 50, no. 7 (July 2001): 569.

ORGANIZATIONS

American Academy of Sleep Medicine. 6301 Bandel Road NW, Suite 101, Rochester, MN 55901. (507) 287-6006. <www.asda.org>.

Tish Davidson, A.M.

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Insomnia

Insomnia

Definition

Insomnia is the inability to obtain an adequate amount or quality of sleep. The difficulty can be in falling asleep, remaining asleep, or both. People with insomnia do not feel refreshed when they wake up. Insomnia is a common symptom affecting millions of people that may be caused by many conditions, diseases, or circumstances.

Description

Sleep is essential for mental and physical restoration. It is a cycle with two separate states: rapid eye movement (REM), the stage in which most dreaming occurs; and non-REM (NREM). Four stages of sleep take place during NREM: stage I, when the person passes from relaxed wakefulness; stage II, an early stage of light sleep; stages III and IV, which are increasing degrees of deep sleep. Most stage IV sleep (also called delta sleep), occurs in the first several hours of sleep. A period of REM sleep normally follows a period of NREM sleep.

Insomnia is more common in women and older adults. People who are divorced, widowed, or separated are more likely to have the problem than those who are married, and it is more frequently reported by those with lower socioeconomic status. Short-term, or transient, insomnia is a common occurrence and usually lasts only a few days. Long-term, or chronic insomnia lasts more than three weeks and increases the risk for injuries in the home, at the workplace, and while driving because of daytime sleepiness and decreased concentration. Chronic insomnia can also lead to mood disorders like depression.

Causes and symptoms

Transient insomnia is often caused by a temporary situation in a person's life, such as an argument with a loved one, a brief medical illness, or jet lag. When the situation is resolved or the precipitating factor disappears, the condition goes away, usually without medical treatment.

Chronic insomnia usually has different causes, and there may be more than one. These include:

  • A medical condition or its treatment, including sleep apnea
  • Use of substances such as caffeine, alcohol, and nicotine
  • Psychiatric conditions such as mood or anxiety disorders
  • Stress, such as sadness caused by the loss of a loved one or a job
  • Disturbed sleep cycles caused by a change in work shift
  • Sleep-disordered breathing, such as snoring
  • Periodic jerky leg movements (nocturnal myoclonus ), which happen just as the individual is falling asleep
  • Repeated nightmares or panic attacks during sleep.

Another cause is excessive worrying about whether or not a person will be able to go to sleep, which creates so much anxiety that the individual's bedtime rituals and behavior actually trigger insomnia. The more one worries about falling asleep, the harder it becomes. This is called psychophysiological insomnia.

Symptoms of insomnia

People who have insomnia do not start the day refreshed from a good night's sleep. They are tired. They may have difficulty falling asleep, and commonly lie in bed tossing and turning for hours. Or the individual may go to sleep without a problem but wakes in the early hours of the morning and is either unable to go back to sleep, or drifts into a restless unsatisfying sleep. This is a common symptom in the elderly and in those suffering from depression. Sometimes sleep patterns are reversed and the individual has difficulty staying awake during the day and takes frequent naps. The sleep at night is fitful and frequently interrupted.

Diagnosis

The diagnosis of insomnia is made by a physician based on the patient's reported signs and symptoms. It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, medications, exercise, and any other information recommended by the physician. If the patient has a bed partner, information can be obtained about whether the patient snores or is restless during sleep. This, together with a medical history and physical examination, can help confirm the doctor's assessment.

A wide variety of healthcare professionals can recognize and treat insomnia, but when a patient with chronic insomnia does not respond to treatment, or the condition is not adequately explained by the patient's physical, emotional, or mental circumstances, then more extensive testing by a specialist in sleep disorders may be warranted.

Treatment

Treatment of insomnia includes alleviating any physical and emotional problems that are contributing to the condition and exploring changes in lifestyle that will improve the situation.

Changes in behavior

Patients can make changes in their daily routine that are simple and effective in treating their insomnia. They should go to bed only when sleepy and use the bedroom only for sleep. Other activities like reading, watching television, or snacking should take place somewhere else. If they are unable to go to sleep, they should go into another room and do something that is relaxing, like reading. Watching television should be avoided because it has an arousing effect. The person should return to bed only when they feel sleepy. Patients should set the alarm and get up every morning at the same time, no matter how much they have slept, to establish a regular sleep-wake pattern. Naps during the day should be avoided, but if absolutely necessary, than a 30 minute nap early in the afternoon may not interfere with sleep at night.

Another successful technique is called sleep-restriction therapy, which restricts the amount of time spent in bed to the actual time spent sleeping. This approach allows a slight sleep debt to build up, which increases the individual's ability to fall asleep and stay asleep. If a patient is sleeping five hours a night, the time in bed is limited to 5-5 1/2 hours. The time in bed is gradually increased in small segments, with the individual rising at the same time each morning; at least 85% of the time in bed must be spent sleeping.

Drug therapy

Medications given for insomnia include sedatives, tranquilizers, and antianxiety drugs. All require a doctor's prescription and may become habit-forming. They can lose effectiveness over time and can reduce alertness during the day. The medications should be taken two to four times daily for approximately three to four weeks, though this will vary with the physician and patient. If the insomnia is related to depression, then an antidepressant medication may be helpful. Over-the-counter drugs such as antihistamines are not very effective in bringing about sleep and can affect the quality of sleep.

Other measures

Relaxing before going to bed will help a person fall asleep faster. Learning to substitute pleasant thoughts for unpleasant ones (imagery training) is a technique that can be very helpful in reducing worry. Another effective measure is the use of audiotapes which combine the sounds of nature with soft relaxing music. These, alone or in combination with other relaxation techniques, can safely promote sleepiness.

Changes in diet and exercise routines can also have a have a beneficial effect. Dietary items to be avoided include drinks that contain caffeine such as coffee, tea and colas, chocolate (which contains a stimulant), and alcohol, which initially makes a person sleepy but a few hours later can have the opposite effect. Maintaining a comfortable bedroom temperature, reducing noise and eliminating light are also helpful. Regularly scheduled morning or afternoon exercise can relax the body. This should be done 3-4 times a week and be sufficient to produce a light sweat.

Alternative treatments

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Incorporating relaxation techniques into bedtime rituals will help a person go to sleep faster, as well as improve the quality of sleep. These methods include meditation, massage, breathing exercises, and a warm bath, scented with rose, lavender (Lavendula officinalis ), marjoram, or chamomile (Matricaria recutita ). Eating a healthy diet rich in calcium, magnesium, and the B vitamins is also beneficial. A high protein snack like yogurt before going to bed is recommended, or a cup of herb tea made with chamomile, hops (Humulus lupulus ), passionflower (Passiflora incarnata ), or St John's Wort (Hypericum perforatum ) to encourage relaxation. Acupuncture and biofeedback have also proven useful.

Prevention

Prevention of insomnia centers around promotion of a healthy lifestyle. A balance of rest, recreation and exercise in combination with stress management, regular physical examinations, and a healthy diet can do much to reduce the risk.

Resources

ORGANIZATIONS

American Sleep Disorders Association. 1610 14th St. NW, Ste. 300, Rochester, MN 55901. (507) 287-6006. http://www.asda.org.

OTHER

"What to Do When You Can't Sleep." The Virtual Hospital Page. University of Iowa. http://www.vh.org.

KEY TERMS

Biofeedback A training technique that enables an individual to gain some element of control over involuntary body functions.

Mood disorder A group of mental disorders involving a disturbance of mood, along with either a full or partial excesseively happy (manic) or extremely sad (depressive) syndrome not caused by any other physical or mental disorder. Mood refers to a prolonged emotion.

Sleep apnea A condition in which a person stops breathing while asleep. These periods can last up to a minute or more, and can occur many times each hour. In order to start breathing again, the person must become semi-awake. The episodes are not remembered, but the following day the client feels tired and sleepy. If severe, sleep apnea can cause other medical problems.

Sleep disorder Any condition that interferes with sleep. At least 84 have been identified, according to the American Sleep Disorders Association.

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insomnia

insomnia, abnormal wakefulness or inability to sleep. The condition may result from illness or physical discomfort, or it may be caused by stimulants such as coffee or drugs. However, frequently some psychological factor, such as worry or tension, is the cause. Mild insomnia may often be relieved by a soothing activity like reading or listening to soft music. Chronic or severe insomnia requires treatment of the underlying physical or psychological disorder. In a few, very rare cases, individuals in certain families are subject to an incurable inherited insomia caused by prions that form plaques in the thalamus; the disease appears suddenly in adulthood and ultimately is fatal.

Many patients respond to the assurance that their sleeplessness is a result of normal anxieties or a treatable physical disorder. Opportunities to ventilate anxieties often ease distress and helps resume normal sleeping patterns. Elderly persons are encourage to exercise more during the day; instructed relaxation, administration of tryptophan, and intake of warm milk helps some patients sleep. Sedatives and hypnotics drugs may be employed if the sleeplessness is impairing the subject's sense of well being. Those who wake because of pain receive an analgesic at bedtime; for those who experience insomnia accompanied with depression, an antidepressant often suffices.

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"insomnia." The Columbia Encyclopedia, 6th ed.. . Encyclopedia.com. 20 Aug. 2017 <http://www.encyclopedia.com>.

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Insomnia

INSOMNIA

DEFINITION


Insomnia is the inability to get an adequate amount of sleep. The difficulty can be in falling asleep, remaining asleep, or both. Insomnia is a common disorder that affects millions of people. It can be caused by many different conditions, diseases, and circumstances.

DESCRIPTION


Insomnia is a very common condition that probably affects most people at one time or another. However, it tends to occur more often in certain groups of people. For example, it is more common in women and older adults. People who are divorced, widowed, or separated seem to have the problem more often than those who are single or married.

Short-term, or transient, insomnia usually lasts no more than a few days. Long-term, or chronic, insomnia lasts for more than three weeks. Long-term insomnia is more of a problem. People who are deprived of sleep for extended periods of time are at risk to themselves and others. They are unable to concentrate normally while conducting daily activities. As a result, they are more likely to have accidents at work or while driving. They may also become moody and depressed. Chronic insomnia may also lead to immune disorders. The body's immune system fights off foreign invaders like bacteria and viruses. When a person does not get enough sleep, his or her immune system does not function properly, leaving them open to infection and disease.

CAUSES


Transient insomnia is often caused by a temporary, upsetting incident in a person's life. For example, an argument with a loved one, a brief illness, or jet lag can cause the disorder. This form of insomnia usually does not require medical treatment. When the incident is resolved, a person's ability to sleep returns.

Insomnia: Words to Know

Biofeedback:
A technique that enables a person to gain some control over involuntary body functions.
Sleep disorder:
Any condition that interferes with sleep. The American Sleep Disorders Association has identified eighty-four different sleep disorders.

Chronic insomnia is caused by one or more of the following factors:

  • A medical condition or a treatment for a medical condition
  • Use of certain substances, such as caffeine, alcohol, and nicotine
  • A psychiatric (mental) condition, such as depression or anxiety
  • Stress, such as sadness caused by the loss of a loved one or a job
  • Changes in one's sleep patterns, as when one's job shift has been changed
  • Breathing problems, such as snoring
  • Jerky leg movements that occur when a person is just falling asleep
  • Nightmares or feelings of panic during sleep

Sometimes insomnia can be caused by the problem itself. That is, a person worries so much about falling asleep that he or she can't get to sleep. The more one worries about falling asleep, the harder it is to do.

SYMPTOMS


Some people with insomnia have trouble falling asleep. Others are able to fall asleep but wake up in the middle of the night and have trouble falling back asleep. Or they doze off but sleep very lightly. People with insomnia wake up in the morning tired and unrested. They continue to be exhausted throughout the day. These sleep patterns are common among the elderly and among those who are depressed (see depressive disorders entry).

Sometimes sleep patterns are reversed. For example, a person may find it difficult to stay awake during the day and may take many naps. Then, at night, they find it hard to go to sleep or to stay asleep.

DIAGNOSIS


Insomnia can be diagnosed easily by listening to a patient's symptoms. A doctor may ask the patient to keep records of his or her daily activities. This record can help the doctor determine the factors causing insomnia. For example, someone who eats just before going to bed may experience insomnia. Changing that person's eating patterns may cure the insomnia. A doctor may also conduct a physical examination to see if there are physical reasons for the insomnia.

People with chronic insomnia may need additional medical help. Some doctors specialize in treating sleep disorders. They can conduct additional tests and suggest treatment for more serious cases.

TREATMENT


Treatment of insomnia first requires finding out the factors that are causing the problem. Removing those factors often leads to a solution for insomnia.

Change in Behavior

People can try a number of things to relieve their insomnia. They should go to bed only when sleepy and use the bedroom only for sleep. Other activities, such as reading, watching television, or snacking, should take place in a different room. If they are unable to go to sleep, they should go into another room and do something relaxing, like reading. Watching television is usually not a relaxing activity as television programs often make people more excited. People should go back to bed only when they feel tired.

People with insomnia should set the alarm and get up at the same time every morning, whether or not they had a good night's sleep. In this way, they establish a regular sleep-wake pattern. They should avoid taking naps during the day. If a nap is necessary, it should be taken early in the afternoon for no more than thirty minutes.

One successful form of treatment is called sleep-restriction therapy. A person first determines how long he or she can sleep at night. The person then remains in bed no longer than that length of time. Each night, the time spent in bed is increased slightly. Under this program, the person gets a little more tired each night, and his or her chance of sleeping improves.

Drug Therapy

The simplest way to deal with insomnia is to use drugs. Sedatives, tranquilizers, and anti-anxiety drugs can help a person sleep, but the use of drugs has some serious side effects. First, they may become habit-forming. A person may get to the point where sleep is possible only if he or she takes the drugs. Also, drugs become less effective over time. A person may have to take more and more of a drug to get the same result. Also, drugs can make a person feel groggy during the day. To avoid these problems, drugs should be used to treat insomnia only with a doctor's advice and under very strict supervision.

Other Measures

Relaxing before going to bed can help a person fall asleep faster. People can learn to substitute pleasant thoughts for unpleasant ones. This technique can reduce the effect of depression, anxiety, and other feelings that prevent people from sleeping properly. Audiotapes can also help a person relax.

Changes in diet and exercise routines can help. Certain foods tend to interfere with sleep and should be avoided in the evening. These foods include coffee, tea, colas, and chocolate (all of which contain caffeine), and alcohol. Alcohol makes a person sleepy at first, but a few hours later it has the opposite effect.

Maintaining a comfortable bedroom temperature, reducing noise, and eliminating light are also helpful. Regularly scheduled morning or afternoon exercise can relax the body.

Alternative Treatment

Many alternative treatments have been suggested for treating the symptoms of insomnia and its underlying causes. Practicing relaxation techniques before bed can help a person fall asleep and sleep more deeply. These techniques include meditation; breathing exercises; and a warm bath that contains rose, lavender, marjoram, or chamomile.

Eating a healthy diet rich in calcium, magnesium, and B vitamins can also be beneficial. Eating a high-protein snack like yogurt before going to bed is also recommended. Some people find that a cup of herbal tea made with chamomile, hops, or St. John's wort helps them relax. Acupuncture (a Chinese therapy that involves the use of fine needles) and biofeedback (therapy that involves behavior modification) have also proved helpful.

PROGNOSIS


While short-term insomnia is disruptive to a person's natural balance, it can usually be solved by the methods described, and is therefore not considered a serious condition. However, chronic insomnia may lead to some serious secondary problems. If not treated, long-term sleep disturbance may lead to injuries due to lack of concentration, or possibly to a weakened immune system, which leaves a person at risk for infection or disease.

PREVENTION


The best way to prevent insomnia is to develop a healthy lifestyle. This includes a balance of rest, recreation, and exercise. People should also learn how to manage stress in their lives. A healthy diet can also reduce the risk of insomnia.

FOR MORE INFORMATION


Books

Bruno, Frank Joe. Get a Good Night's Sleep: Understand Your SleeplessnessAnd Banish It Forever! New York: Macmillan General Reference, 1997.

Davies, Dilys. Insomnia: Your Questions Answered. New York: Penguin USA, 1999.

Idzikowski, Chris. The Insomnia Kit: Everything You Need for a Good Night's Sleep. New York: Penguin USA, 1999.

Simpson, Carolyn. Coping With Sleep Disorders. New York: Rosen Publishing Group, 1996.

Organizations

American Sleep Disorders Association. 6301 Bandel Road, Suite 101, Rochester, MN 55901. http://www.asda.org.

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Insomnia

Insomnia

Why Cant I Sleep?

What to Do about Insomnia

Insomnia (in-SOM-nee-a) is a disorder in which people have trouble sleeping or getting enough rest.

KEYWORDS

for searching the Internet and other reference sources

Sleep disorders

Sleeplessness

Why Cant I Sleep?

Humans, like all earths creatures, have cycles of activity and rest, which perhaps evolved partly as a response to the cycles of night and day. Many of the bodys hormones* and processes are related closely to such daily cycles. Sleep provides the opportunity to rest, to restore certain essential neurotransmitters*, and even to avoid certain predators. Sleep, in short, is necessary to health and even to life.

* hormones
are chemicals that are produced by different glands in the body. Hormones are like the bodys ambassadors: they are created in one place but are sent through the body to have specific regulatory effects in different places.
* neurotransmitters
(NOOR-o-TRANS-mit-urz) are brain chemicals that let brain cells communicate with each other and therefore allow the brain to function normally.

Millions of Americans have insomnia. They may have difficulty falling asleep or staying asleep through the night, or they may wake up too early or sleep so restlessly that the body and mind are not refreshed. Insomnia is not defined by how long it takes to fall asleep or by how many hours a person sleeps, because these characteristics vary greatly from person to person. Babies may sleep 16 to 20 hours a day, and school-age children need between 8 and 10 hours a night. Some adults need 7 to 8 hours of sleep a night, whereas others function perfectly well with just 3 to 4 hours. Instead, people are diagnosed with insomnia when sleep problems begin to interfere with daily livingwhen they can no longer function normally during the day because of being tired or cranky, having no energy, and being unable to concentrate.

Everyone has trouble sleeping sometimes. Young people who are excited about a holiday or stressed about an exam might have trouble falling asleep. Adults who are worried about a sick relative or stressed at work might wake up in the middle of the night and not be able to fall back asleep. These are examples of short-term, or transient, insomnia, which are sleep problems that last for one night or even for a few weeks and then disappear. In other cases, episodes of short-term insomnia come and go; this is considered intermittent insomnia. But half of all people with insomnia have chronic* insomnia, which is a sleep problem that occurs on most nights for a month or longer.

* chronic
(KRON-ik) means continuing for a long period of time.

Insomnia affects people of all ages, but it is most common in older people, especially women. When people travel, start a new job, or move to a new home or school, all of which are changes in routine, they can have trouble sleeping. Physical conditions such as pregnancy, arthritis, the need to urinate frequently, and leg cramps also seem to cause sleep problems. But the most common cause of insomnia is psychological*; emotions such as anger, anxiety, depression*, and stress keep many people from sleeping well.

* psychological
(sy-ko-LOJ-i-kal) refers to mental processes, including thoughts, feelings, and emotions.
* depression
(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.

What to Do about Insomnia

If insomnia is transient, it should go away when the stress that triggered it eases, such as when that worrisome exam is over. For underlying psychological or physical issues, seeing a doctor can help improve sleep. Dealing with insomnia, however, is often a matter of lifestyle changes. Things that may contribute to insomnia include:

  • Reading, eating, or watching television in bed (use a bed only for sleeping)
  • Taking afternoon naps
  • Smoking
  • Drinking alcohol
  • Drinking coffee, tea, cocoa, colas, or other drinks that contain caffeine late in the day
  • Taking sleeping pills not prescribed by a doctor

Things that may contribute to a better nights sleep include:

  • Keeping to a sleep schedule, which means going to sleep and getting up at the same time every day
  • Exercising during the day (but not after dinner)
  • Taking a warm bath before bedtime
  • Drinking warm milk before bedtime

See also

Jet Lag

Sleep Apnea

Sleep Disorders

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insomnia

insomnia (in-som-niă) n. inability to fall asleep or to remain asleep for an adequate length of time. Insomnia may be associated with physical disease or depression, but is more often caused by worry. See also fatal familial insomnia.

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insomnia

in·som·ni·a / inˈsämnēə/ • n. habitual sleeplessness; inability to sleep. DERIVATIVES: in·som·ni·ac / -nēˌak/ n. & adj.

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insomnia

insomnia Inability to sleep. It may be caused by anxiety, pain or stimulants such as drugs.

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insomnia

insomnia XVIII. — L., f. insomnis sleepless (f. IN-2 + somnus sleep) + -IA1.

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insomnia

insomniaCampania, Catania, pannier •apnoea •Oceania, Tanya, Titania •biennia, denier, quadrennia, quinquennia, septennia, triennia •Albania, balletomania, bibliomania, crania, dipsomania, egomania, erotomania, kleptomania, Lithuania, Lusitania, mania, Mauritania, megalomania, miscellanea, monomania, nymphomania, Pennsylvania, Pomerania, pyromania, Rainier, Romania, Ruritania, Tasmania, Transylvania, Urania •Armenia, bergenia, gardenia, neurasthenia, proscenia, schizophrenia, senior, SloveniaAbyssinia, Bithynia, curvilinear, Gdynia, gloxinia, interlinear, Lavinia, linear, rectilinear, Sardinia, triclinia, Virginia, zinnia •insignia • Sonia • insomnia • Bosnia •California, cornea •Amazonia, ammonia, Antonia, Babylonia, begonia, bonier, Catalonia, catatonia, Cephalonia, Estonia, Ionia, Laconia, Livonia, Macedonia, mahonia, Patagonia, pneumonia, Rondônia, sinfonia, Snowdonia, valonia, zirconia •junior, petunia •hernia, journeyer

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