Article on Insomnia by AskDocWeb

About Insomnia?

In 2002 the National Sleep Foundation polled Americans about their sleep problems. The poll revealed that 58% of adults experienced symptoms of insomnia a few nights a week or more. 45% of those under 55 experienced frequent symptoms and 62% of those over 55 have frequent symptoms.

Types of Insomnia

There are various types of insomnia, each with varying degrees of severity:

1. Transient insomnia may last from one day to a week.

2. Short-term insomnia may last from one to three weeks.

3. If you are unable to consistently sleep well for a period of between three weeks to six months, it’s called acute insomnia.

4. Chronic insomnia may last from three weeks to a year or more.

Insomnia Patterns

The pattern of your insomnia typically falls into one of the following patterns.

1. Onset insomnia is when you have difficulty falling asleep at the beginning of the night.

2. Middle-of-the-Night Insomnia (middle insomnia) is characterized by difficulty returning to sleep after awakening in the middle of the night. Also referred to as nocturnal awakenings.

3. Terminal (or late) insomnia is waking up too early in the morning.

Symptoms of Insomnia

The consequences of insomnia are impaired performance, similar to those of sleep deprivation. Its effects can vary according to its causes. Symptoms may include one or more of the following;

  • Double vision
  • Hallucinations
  • Mental fatigue
  • Muscular fatigue
  • Sleepiness

People with chronic insomnia often show increased alertness. Some people report seeing things as though they were happening in slow motion and moving objects seem to blend together.

Causes of insomnia

There are many possible causes insomnia. It can be caused by another disorder or it can be a primary disorder. Certain mental disorders have been associated with a specific pattern of insomnia.

  • Onset insomnia is often associated with anxiety disorders.
  • Middle insomnia is often associated with pain disorders or medical illness.
  • Terminal (or late) insomnia is characteristic of clinical depression.

Most insomnia is caused by one or more of the following:

  • Abuse of sleeping pills can produce rebound insomnia
  • Brain lesions
  • Caffeine
  • Changes in the sleep environment
  • Changes in your sleep schedule
  • Herbs
  • Hormone shifts that precede menstruation
  • Hormone shifts during menopause
  • Hyperthyroidism
  • anxiety
  • emotional or mental tension
  • fear
  • financial stress
  • jet lag
  • problems with work
  • stress
  • unsatisfactory sex life
  • Magnesium deficiency
  • bipolar disorder
  • clinical depression
  • general anxiety disorder
  • obsessive compulsive disorder
  • post traumatic stress disorder
  • schizophrenia
  • Neurological disorders
  • Psychoactive drugs
  • Sleep apnea
  • Too much or unpleasant noise
  • Too bright a light
  • Too hot or too cold
  • Traumatic brain injury
  • Wilson’s syndrome

Diagnosing Insomnia

Diagnosing the many different sleep disorders is best done by specialists in sleep medicine. These are board certified sleep physicians.

Treatments for Insomnia

It is important to identify the cause of your insomnia before deciding on a treatment. Medical causes and psychological causes of insomnia have very different treatments.

Non-drug Strategies

Non-pharmacological strategies are superior to hypnotic medications, such as Ambien, for insomnia because;

  • tolerance develops
  • dependence can develeop
  • rebound withdrawal effects

Because of this, hypnotic medications are only recommended for short term use. Non pharmacological strategies have long lasting improvements and are recommended as a first line of managing insomnia. These strategies include;

  • attention to sleep hygiene
  • behavioral interventions
  • patient education
  • relaxation therapy
  • sleep-restriction therapy
  • stimulus control

Cognitive Behavior Therapy

In cognitive behavior therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. The effects of cognitive behavior therapy have a lasting effect on treating insomnia long after the therapy has been discontinued.

Drugs for Insomnia

Sleeping tablets and other sedatives have the potential of causing psychological dependence. This happens when the individual comes to believe that they can’t sleep without the drugs. In reality it is just the oppisite. Chronic users of hypnotic medications 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. This is why short term or occasional use of hypnotics can be benefitial but long term use may be detrimental to sleep.

Benzodiazepines for Insomnia

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. These drugs unselectively bind to the GABAA receptor. Both benzodiazepine and nonbenzodiazepine hypnotic medications 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. These sedatives may also cause physical dependence which may manifest in withdrawal symptoms. These include drugs such as flunitrazepam, temazepam, triazolam, midazolam, flurazepam, nitrazepam and quazepam. While benzodiazepines induce unconciousness, they actually worsen sleep because they promote light sleep whilst decreasing time spent in deep sleep such as REM sleep. An additional problem is that with regular use, day time rebound anxiety can emerge.

Non-benzodiazepines for Insomnia

Nonbenzodiazepine sedative-hypnotic drugs, such as Ambien (zolpidem), Sonata (zaleplon), Imovane (zopiclone) and Lunesta (eszopiclone), are a newer classification of hypnotic medications. There is some controversy about 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. They may also cause the same memory and cognitive disturbances along with morning sedation.

Antidepressants for Insomnia

Some older antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone may have a sedative effect and are prescribed off-label to treat insomnia. The major drawback of these drugs is that they have too many side effects. The use of antidepressants in the treatment of insomnia can also lead to physical dependence and withdrawal may induce rebound insomnia which further complicates the problem in the long-term.

Melatonin for Insomnia

Melatonin is effective in several types of insomnia and has demonstrated effectiveness equivalent to the prescription sleeping pill zopiclone in inducing sleep and regulating the sleep cycle. One particular benefit of melatonin is that it does not impair performance related skills. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence.
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 for Insomnia

Antihistamines with sedative properties [for example, diphenhydramine (Benadryl) used in Tylenol PM or doxylamine] are widely used in nonprescription sleep aids. While 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. It appears that dependence is not an issue with this class of drugs but antihistamines do not improve sleep and should not be used to treat chronic insomnia.

Atypical Antipsychotics for Insomnia

Certain atypical antipsychotics such as quetiapine (Seroquel) are prescribed in low doses for their sedative effect but because of the possibility of neurological and cognitive side effects these drugs make a poor choice to treat insomnia. Over time the body builds up a tolerance to Seroquel and it may lose its ability to produce sleep.

Herbs for Insomnia

Herbs such as valerian, hops, chamomile, evening primrose, lavender, and passion-flower have all been reported to provide some relief from insomnia. There have been multiple studies of Valerian and it appears to be modestly effective. Cannabis has also been proven to be an effective treatment for insomnia.

Anecdotal Remedies of Insomnia

Some people get good results from the use of an elixir of cider vinegar and honey but so far the evidence for this is only anecdotal. Other anecdotal remedies include:

  • drinking warm milk before bedtime
  • taking a warm bath
  • a half hour of vigorous exercise in the afternoon
  • eating a large lunch and a light evening meal
  • avoiding mentally stimulating activities 3 hours before bedtime
  • going to bed at a reasonable hour and getting up early
  • avoid too much light, especially blue light before bedtime
  • aromatherapy (jasmine or lavender oil)
  • listening to slow paced music
  • relaxation techniques such as meditation
  • deep breathing technique
  • hypnotherapy or self hypnosis
  • guided imagery
  • visualizing

For a more extensive list of tips click here

When to call a doctor

If insomnia lasts longer than three to four weeks call a doctor.

If insomnia interferes with your daytime activities call a doctor.

If insomnia interferes with your ability to function call a doctor.

For More Information

National Sleep Foundation

1522 K Street, NW, Suite 500,

Washington, DC 20005

(202) 347-3471

American Academy of Sleep Medicine

One Westbrook Corporate Center, Suite 920

Westchester, IL 60154

(708) 492-0930

American Sleep Association

614 South 8th St, Suite 282

Philadelphia, PA 19147

(443) 593-2285

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