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Insomnia is defined as difficulty initiating, or maintaining sleep at least 3 nights per week, in addition to complaints of sleep-related daytime impairment. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than 8 hours of sleep a day, but only 35% of American adults consistently get this amount of rest.
People with insomnia tend to experience one or more of the following sleep disturbances:
Insomnia may stem from a disruption of the body's circadian rhythm, an internal clock that governs the timing of hormone production, sleep, body temperature, and other functions. While occasional restless nights are normal, prolonged insomnia can interfere with daytime function, concentration, and memory. Insomnia increases the risk of substance abuse, motor vehicle accidents, headaches, and depression. Recent surveys indicate that 50% of people suffer from sleep difficulties, and 20 - 36% of them struggle with such difficulties for at least 1 year. Other studies show that one person out of three in the United States has insomnia, but only 20% tell their health care providers about it.
Signs and Symptoms
Signs of insomnia may include:
No known physical or mental condition causes primary insomnia, although doctors suspect it 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. Everyday anxiety and stress, coffee, and alcohol are the most common culprits.
An underlying medical or psychological condition, such as depression, often causes secondary insomnia. Studies show that 40 - 60% of people who have insomnia show signs of depression.
About 50% of insomnia cases have no identifiable cause.
Some conditions or situations that commonly lead to insomnia include:
The following factors may increase an individual's risk for insomnia:
Clinical history (including all current medication and recreational drug use) and physical exam are usually sufficient to make the diagnosis. Polysomnography, an overnight sleep study, can be helpful to rule out other types of sleep disorders (such as breathing related sleeping disorder).
The following lifestyle changes can help prevent insomnia:
The preferred treatments for people with chronic insomnia are lifestyle changes and behavioral approaches that establish healthy sleeping habits. This is called improving sleep hygiene.
Mind-body therapies -- such as stimulus control therapy, bright light therapy, mindfulness-based stress reduction, and cognitive behavioral therapy -- are particularly helpful.
Acupuncture and acupressure have a long tradition of treating insomnia successfully, particularly in the elderly. Vitamins, along with homeopathic and herbal remedies, may also improve symptoms in some individuals.
Healthy sleep habits are essential for treating insomnia. The following strategies (in addition to the steps mentioned in the "Preventive Care" section) may help treat the condition:
If changes in sleep hygiene do not help, prescription medications (including benzodiazepines) may be appropriate. Benzodiazepines include temazepam (Restoril), flurazepam (Dalmane), estazolam (ProSom), and triazolam (Halcion). Benzodiazepines may cause psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heartbeat.
Another class of sedative hypnotic medications includes the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and fewer adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta).
Ramelteon (Rozerem) belongs to a new class of drugs called melatonin agonists. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize circadian rhythm and sleep/wake cycles. Side effects may include daytime sleepiness, dizziness, and fatigue.
Over-the-counter (OTC) antihistamines may be used short term for insomnia. Diphenhydramine (Benadryl) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl, Nytol, Sominex) or in combination with other OTC items, such as acetaminophen (Tylenol PM). Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation. Do not combine OTC remedies with your prescription sleep aids.
Generally, OTC and prescription medications help promote sleep, but they are not recommended for insomnia that lasts for more than 4 weeks. Long-term use of some medications may cause addiction, particularly if the patient has a history of substance abuse.
Nutrition and Dietary Supplements
Following these nutritional tips may help reduce symptoms:
The following dietary supplements may also be helpful in promoting sleep:
L-tryptophan and 5-hydroxytryptophan (5-HTP)
Medical research indicates that taking 1 g L-tryptophan before bedtime can induce sleepiness and delay wake times. Researchers think L-tryptophan brings on sleep by raising levels of serotonin, a body chemical that promotes relaxation. However, consumers should take this supplement with caution as it may adversely interact with certain antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), and cause serious negative side effects. Reports of eosinophilia myalgia syndrome (EMS: an autoimmune disorder characterized by fatigue, fever, muscle pain and tenderness, cramps, weakness, hardened skin, and burning, tingling sensations in the extremities) from contaminated L-tryptophan supplements surfaced in 1989, and isolated incidents of EMS continue to be reported.
Studies also suggest that 5-hydroxytryptophan (5-HTP), made from tryptophan in the body or available in supplement form, may be useful in treating insomnia associated with depression. Like tryptophan, reports of EMS have been associated with use of 5-hydroxytryptophan. Talk to a health care professional before taking 5-HTP supplements if you are on antidepressant medications. Drug interactions may occur.
Melatonin supplements help induce sleep, particularly in people who have disrupted circadian rhythms (such as from jet lag or shift work), or those with low levels of melatonin (such as some people with schizophrenia). In fact, a review of scientific studies found that melatonin supplements help prevent jet lag, particularly in people who cross five or more time zones. A few clinical studies suggest that melatonin is significantly more effective than placebo, or dummy pill, in decreasing the amount of time required to fall asleep, increasing the number of sleeping hours, and boosting daytime alertness. Although research suggests that melatonin may be modestly effective for treating certain types of insomnia, few studies have investigated whether melatonin supplements are safe and effective for long term use. More research is needed.
As with any therapy, you should work with your health care provider before starting treatment with herbs. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted:
A few studies have examined the effectiveness of specific homeopathic remedies. However, a professional homeopath may recommend one or more of the following treatments for insomnia, based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
Some reports suggest that certain acupuncture procedures have a nearly 90% success rate for the treatment of insomnia. Through a complex series of signals to the brain, acupuncture increases the amount of certain substances in the brain, such as serotonin, which promote relaxation and sleep.
Several clinical studies have found that auricular acupuncture, using needles placed at various point in the ear, is effective in reducing symptoms of insomnia, such as difficultly in falling asleep and remaining asleep. Further studies should be performed.
Clinical studies of elderly people with sleep disturbances suggest that acupressure enhances sleep quality and decreases awakenings during the night. An acupressure practitioner works with the same points used in acupuncture, but stimulates these healing sites with finger pressure, rather than inserting fine needles. Clinical studies support the use of auricular (ear) acupressure for improving sleep quality in elderly patients and possibly in healthy adults of all ages. A small clinical study also found that acupressure may help with sleep apnea.
No well-designed studies have evaluated the effect of chiropractic care on individuals with insomnia, but chiropractors report that spinal manipulation may improve symptoms of the condition in some individuals. In these cases, spinal manipulation may have a relaxing effect on the nervous system.
Massage and Aromatherapy
Massage has long been known to enhance relaxation and improve sleep patterns. While massage alone is an effective method for relaxation, studies suggest that massage with essential oils (called aromatherapy), particularly lavender (Lavandula angustifolia), may result in improved sleep quality, more stable mood, increased mental capacity, and reduced anxiety. Clinical studies have found participants who received massage with lavender felt less anxious and more positive than participants who received massage alone.
A variety of behavioral techniques have proved helpful in treating insomnia. These methods, with the guidance of a sleep specialist or a sleep specialty team, are singly used to treat insomnia, but they may also be combined with other treatment methods including:
Traditional Chinese Medicine
Many methods have been used historically in Traditional Chinese Medicine to treat insomnia, including herbal remedies, acupuncture, acupressure, Chinese massage (tui na), and qi gong.
Warnings and Precautions
Prognosis and Complications
Most people who have insomnia with no underlying medical conditions recover within a few weeks. For those who develop insomnia from a traumatic event (such as those with posttraumatic stress disorder), sleep disruptions can continue indefinitely. People who become dependent on sleeping pills and prescription medication for sleep often have the most difficulty overcoming insomnia. Chronic insomnia can encourage the development of a medical condition, a mental disorder, and road, work, and domestic accidents.
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Review Date: 1/20/2012
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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