insomnia

Common Sleeping Problems Find out how you can get a good night's sleep.

More about Insomnia: Causes and symptoms Diagnosis Treatment Alternative treatments Prevention Resources

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 of 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.

— Donald G. Barstow, RN

Chronic inability to fall asleep or remain asleep for an adequate length of time.

[Latin īnsomnia, from īnsomnis, sleepless : in-, not; see in–¹ + somnus, sleep.]

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The ability to sleep can be affected by diet and exercise. The nervous anticipation experienced before a major sports competition commonly causes insomnia. People who consume certain foods and drinks (e.g. those which contain caffeine or high levels of salt) may also suffer from the condition. On the other hand, certain foods and drinks (e.g. warm milk) seem to be conducive to a good night's sleep. Also, a vigorous bout of exercise taken during the day (but not immediately before going to bed) may be sufficiently tiring physically to help a person get to sleep.

Many insomniacs resort to taking drugs (‘sleeping tablets’) to induce sleep, but frequent use should be discouraged. Some drugs, such as the benzodiazepines, are habit forming and have side-effects such as inducing drowsiness when awake, which adversely affect physical performance. Moderate exercise, a change of diet, and relaxation techniques (see progressive muscle relaxation) may help a person overcome insomnia.

Definition: inability to sleep soundly
Antonyms: sleep

The chronic inability to sleep or remain asleep throughout the night.

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 5–5.5 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. .

National Sleep Foundation. 1522 K St. NW, Suite 510, Washington, DC 20005. .

Other

"Acupuncture and Insomnia." Alternative Medicine Update (October 1999). .

"Insomnia." CBS Health Watch. .

"Patient Information: Insomnia and What You Can Do to Sleep Better." American Family Physician. 49, no. 6 (May 1, 1994). (1998).

"Sleep Aids: Everything You Wanted to Know…But Were Too Tired to Ask." National Sleep Foundation, 1999. .

"What to Do When You Can't Sleep." Children's Hospital of Iowa. 1995. (1998).

Willard, Terry. "Insomnia: Wake up to ten simple solutions." Herbs for Health. HealthWorld Online. .

[Article by: Liz Swain]

For more information on insomnia, visit Britannica.com.

Difficulty in falling asleep or an inability to stay asleep. Although chronic insomnia is relatively rare, the nervous anticipation an athlete experiences before a major competition often causes sleep difficulties. The use of hypnotics, such as benzodiazepines, induce sleep, but they can be habit forming and have adverse side-effects (for example, drowsiness, which decreases reaction times) that adversely affect physical performance. Relaxation techniques, such as progressive muscle relaxation, and sensible eating and drinking habits (e.g. avoiding a heavy or salty meal before going to bed) may help athletes overcome insomnia. Moderate exercise may also help some insomniacs, but strenuous exercise before retiring is likely to increase arousal and make sleep more difficult.

A persistent and prolonged inability to sleep.

Quotes:

"O sleep, O gentle sleep, nature's soft nurse, how have I frightened thee, that thou no more wilt weigh my eye-lids down and steep my senses in forgetfulness?" - William Shakespeare

"Impossible to spend sleepless nights and accomplish anything: if, in my youth, my parents had not financed my insomnias, I should surely have killed myself." - E. M. Cioran

"The last refuge of the insomniac is a sense of superiority to the sleeping world." - Leonard Cohen

This article is about the sleeping disorder. For other uses, see Insomnia (disambiguation).

Insomnia
Classification and external resources
ICD-10	F51.0, G47.0
ICD-9	307.42, 307.41, 780.51, 780.52
DiseasesDB	26877
eMedicine	med/2698
MeSH	D007319

Insomnia is a symptom^[1] of any of several sleep disorders, 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. Both organic and non-organic insomnia without other cause constitute a sleep disorder, primary insomnia.^[2]

According to the United States Department of Health and Human Services in the year 2007, approximately 64 million Americans regularly suffer from insomnia each year.^[3] Insomnia is 1.4 times more common in women than in men.^[4]

Contents 1 Types of insomnia 2 Patterns of insomnia 3 Causes 4 Epidemiology 5 Diagnosis 6 Sleep duration and mortality 7 Insomnia versus poor sleep quality 8 Treatment for insomnia 8.1 Non-pharmacological strategies 8.1.1 Cognitive behavior therapy 8.2 Medications 8.2.1 Benzodiazepines 8.2.2 Non-benzodiazepines 8.2.3 Antidepressants 8.2.4 Melatonin and melatonin agonists 8.2.5 Antihistamines 8.2.6 Atypical antipsychotics 8.2.7 Other substances 9 See also 10 References

Types of insomnia

Although there are several different degrees of insomnia, three types of insomnia have been clearly identified: transient, acute, and chronic.

1. 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.^[5]
2. Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.^[6]
3. 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.^[5]

Patterns of insomnia

The pattern of insomnia often is related to the etiology.^[7] Insomnia affects 1 in 3 people.

1. Onset insomnia - difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
2. 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.
3. Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with pain disorders or medical illness.
4. Terminal (or late) insomnia - early morning waking. Often a 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 ^[8]
• 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, generalized 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.^[9][10]
• Certain neurological disorders, brain lesions, or a history of traumatic brain injury
• Medical conditions such as hyperthyroidism and rheumatoid arthritis^[11]
• 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.^{[citation needed]}

Sleep studies using polysomnography have suggested that people who have insomnia with sleep disruption have elevated nighttime levels of circulating cortisol and adrenocorticotropic hormone They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study. Studies of brain metabolism using positron emission tomography (PET) scans indicate that people with insomnia have higher metabolic rates by night and by day. The question remains whether these changes are the causes or consequences of long-term insomnia.^[11]

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.

A common misperception is that the amount of sleep required decreases as a person 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.^[12]

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.^[13] 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.^[13]

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.

Potential complications of insomnia.^[14]

If a patient has trouble getting to sleep, but has normal sleep pattern once asleep, a circadian rhythm disorder is a likely cause.

Sleep duration and mortality

A survey of 1.1 million residents in America found that those who reported sleeping about 7 hours per night had the lowest rates of mortality, whereas those who slept for fewer than 6 hours or more than 8 hours had higher mortality rates. Getting 8.5 or more hours of sleep per night increased the mortality rate by 15%. Severe insomnia - sleeping less than 3.5 hours in women and 4.5 hours in men - also led to a 15% increase in mortality. However, most of the increase in mortality from severe insomnia was discounted after controlling for comorbid disorders. After controlling for sleep duration and insomnia, use of sleeping pills was also found to be associated with an increased mortality rate. The lowest mortality was seen in individuals who slept between six and a half and seven and a half hours per night. Even sleeping only 4.5 hours per night is associated with very little increase in mortality. Thus mild to moderate insomnia for most people may actually increase longevity and severe insomnia has only a very small effect on mortality. As long as a patient refrains from using sleeping pills there is little to no increase in mortality associated with insomnia but there does appear to be an increase in longevity. This is reassuring for patients with insomnia in that despite the sometimes unpleasantness of insomnia, insomnia itself appears to be associated with increased longevity. It is unclear why sleeping longer than 7.5 hours is associated with excess mortality.^[15]

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.^[16]

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.^[17] Attention to sleep hygiene is an important first line treatment strategy and should be tried before any pharmacological approach is considered.^[18]

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 strategy of managing insomnia. The strategies include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, patient education and relaxation therapy.^[19]

Cognitive behavior therapy

A recent study found that cognitive behavior therapy is more effective than hypnotic medications in controlling insomnia.^{[citation needed]} 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.^[20][21] 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.^[22]

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^{[citation needed]}. 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.^[23]

In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was not significantly more than for antidepressants.^[24] Benzodiazepines did not have a significant tendency for more adverse drug reactions.^[24] 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.^[25] A further review of the literature regarding benzodiazepine hypnotic as well as the nonbenzodiazepines concluded that these drugs caused an unjustifiable risk to the individual and to public health and lack evidence of long term effectiveness. The risks include dependence, accidents and other adverse effects. Gradual discontinuation of hypnotics in long term users leads to improved health without worsening of sleep. Preferably hypnotics should be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible in the elderly.^[26]

Benzodiazepines

Main article: Benzodiazepine

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABA_A receptor.^[24] 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.^[27] A further problem is with regular use of short acting sleep aids for insomnia, day time rebound anxiety can emerge.^[28]

Non-benzodiazepines

Main article: Nonbenzodiazepine

Nonbenzodiazepine sedative-hypnotic drugs, such as zolpidem, zaleplon, zopiclone and eszopiclone, are a newer classification of hypnotic medications. They work on the benzodiazepine site on the GABA_A receptor complex similarly to the benzodiazepine class of drugs. Some but not all of the nonbenzodiazepines are selective for the α₁ subunit on GABA_A 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 α₁, α₂, α₃ and α₅ GABA_A benzodiazepine receptors.^[29] Zolpidem is more selective and zaleplon is highly selective for the α₁ subunit, thus giving them an advantage over benzodiazepines in terms of sleep architecture and a reduction in side effects.^[30][31] 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

Main article: 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. ^[32] 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 efficiency and increasing the total amount of sleeping time in patients suffering from both depression and insomnia ^{[33] [34]}

Melatonin and melatonin agonists

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.^[35] One particular benefit of melatonin is that it can treat insomnia without altering the sleep pattern which is altered by many prescription sleeping tablets. Another benefit is it does not impair performance related skills.^[36][37]

Melatonin agonists, including ramelteon (Rozerem) and tasimelteon, 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. While these drugs show good effects for the treatment of insomnia due to jet lag,^[38] the results for other forms of insomnia are less promising.^[39]

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.^[40]

Antihistamines

The antihistamine 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 25 mg to 50 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.

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.^[41]

Atypical antipsychotics

Low doses of certain atypical antipsychotics such as quetiapine, olanzapine and risperidone 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, quetiapine may lose its effectiveness as a sedative. The ability of quetiapine 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.

Eplivanserin is an investigational drug with a mechanism similar to these antipsychotics, but probably with less side effects.

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.^[42][43][44] Cannabis has also been proven as an effective treatment for insomnia. ^[45]

Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, 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.^[46]

See also

• Sleep
• Sleep disorder
• Fatal familial insomnia
• Sleep deprivation
• Delayed sleep phase syndrome
• Actigraphy
• Thai Ngoc

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Dansk (Danish)
n. - søvnløshed

Nederlands (Dutch)
slapeloosheid

Français (French)
n. - insomnie

Deutsch (German)
n. - Schlaflosigkeit

Ελληνική (Greek)
n. - αϋπνία

Italiano (Italian)
insonnia

Português (Portuguese)
n. - insônia (f)

Русский (Russian)
бессонница

Español (Spanish)
n. - insomnio

Svenska (Swedish)
n. - sömnlöshet

中文（简体）(Chinese (Simplified))
不眠症

中文（繁體）(Chinese (Traditional))
n. - 不眠症

한국어 (Korean)
n. - 불면증

日本語 (Japanese)
n. - 不眠症, 不眠

العربيه (Arabic)
‏(الاسم) أرق‏

עברית (Hebrew)
n. - ‮נדודי שינה‬

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