Information about Insomnia

Classification & 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 sleeping disorder characterized by the inability to fall asleep and/or the inability to remain asleep for a reasonable amount of time. Insomniacs have been known to complain about being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and non-organic insomnia constitute a sleep disorder.^[1][2]

According to the U.S. Department of Health and Human Services, approximately 60 million Americans suffer from insomnia each year.^[3] Insomnia tends to increase with age and affects about 40 percent of women and 30 percent of men ^[4].

Types of Insomnia

At least three types of insomnia exist: transient, acute, and chronic.

1. Transient insomnia lasts from one night to a few weeks. Most people occasionally suffer from transient insomnia due to such causes as jet lag or short-term anxiety. If this form of insomnia continues to occur from time to time, the insomnia is classified as intermittent.
2. Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.
3. Chronic insomnia is regarded as the most serious; persists almost nightly for at least a month.

Causes

Insomnia can be caused by:

• Psychoactive drugs or stimulants, including certain medication, herbs, caffeine, cocaine, ephedrine, amphetamines, methylphenidate, MDMA, methamphetamine and modafinil
• Hormone shifts such as those that precede menstruation and those during menopause
• Psychological problems like fear, stress, anxiety, emotional or mental tension, work problems, financial stress, unsatisfactory sex life
• Mental Disorders such as clinical depression, bipolar disorder, general anxiety disorder, sleep disorders
• 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 falling 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.
• Certain neurological disorders, brain lesions, or a history of Traumatic brain injury
• Medical conditions such as Hyperthyroidism and Wilson's Syndrome
• Abuse of over-the counter or prescription sleep aids can produce Rebound insomnia
• Poor sleep hygiene
• 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

A common misperception is that the amount of sleep a person requires decreases as he or she ages. The ability to sleep for long periods, rather than the need for sleep, appears to be lost as people get older. Some elderly insomniacs toss and turn in bed and occasionally fall off the bed at night, diminishing the amount of sleep they receive.^[5]

An overactive mind or physical pain may also be causes. Finding the underlying cause of insomnia is usually necessary to cure it. Insomnia can be common after the loss of a loved one, even years or decades after the death, if they have not gone through the grieving process.

Diagnosis

Patients with DSPS are often mis-diagnosed with insomnia. If the patient has trouble getting to sleep, but has normal sleep architecture once asleep, a circadian rhythm disorder is a more likely cause.

Insomnia Versus Poor Sleep Quality

Poor sleep quality can occur as a result of sleep apnea or major 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 still 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 hypothalamus and pituitary causing excessive release of cortisol which can lead to poor sleep quality.

Nocturnal polyuria or excessive nighttime urination can be very disturbing to sleep.^[6] Nocturnal polyuria can be nephrogenic (related to kidney disease) or it may be due to prostate enlargement or hormonal influences. Deficiencies in vasopressin, which is either caused by a pituitary problem or by insensitivity of the kidney to the effects of vasopressin, can lead to nocturnal polyuria. Excessive thirst or the use of diuretics can also cause these symptoms.

Treatment for Insomnia

In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful.

Medications

Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.

In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was insignificantly more than for antidepressants.^[7] Benzodiazepines had an insignificant tendency for more adverse drug reactions.^[7]

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.^[7] This includes drugs such as temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long periods of time.

Non-benzodiazepines

Main article: Nonbenzodiazepine

Nonbenzodiazepine prescription drugs, including the nonbenzodiazepines zolpidem(Stilnoct) and zopiclone(Imovane), are more selective for the GABA_A receptor^[7] and may have a cleaner side effect profile than the older benzodiazepines; 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, and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.

Antidepressants

Main article: Antidepressants

Some antidepressants such as mirtazapine, trazodone and doxepin have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture.

Melatonin

Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation.

Antihistamines

The antihistamine diphenhydramine is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.

Atypical Antipsychotics

Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.

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.^[8][9][10] Cannabis has also been suggested as a very effective treatment for insomnia. ^[11]

Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.

Insomnia may be a symptom of magnesium deficiency, or lower magnesium levels. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.^[12]

Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal. ^[13]

Non-medicinal, Complimentary and Alternative medicine

Recent research has shown that cognitive behavior therapy can be more effective than medication in controlling insomnia [1]. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep.^[14]

Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get up early in the morning and to retire to bed at a reasonable hour.

Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness. Horlicks is marketed as a sleeping aid.

Many believe that listening to slow paced music will help insomniacs fall asleep. ^[15]

The more relaxed a person is, the greater the likelihood of getting a good night's sleep. Relaxation techniques such as meditation have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.

Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, herbology and other techniques, with the goal of resolving the problem at a subtle level.

In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or metta. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body^[16]. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the Mettā (Mettanisamsa) Sutta^[17], Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.

Hypnotherapy, self hypnosis and guided imagery can be effective in not only falling asleep and staying asleep; they can also help to develop good sleeping habits over time. Visualizing can be effective in taking the mind away from present day anxieties and towards a more relaxing place.

See also

• Fatal familial insomnia
• Sleep deprivation
• Delayed sleep phase disorder
• Actigraphy
• Causes of insomnia

References

External links

• Insomnia from NHS
• State of the science report on management of chronic insomnia in adults from NIH
• Insomnia from Sleeptionary at National Sleep Foundation
• Overview from American Academy of Sleep Medicine
• Insomnia at FamilyDoctor.org, from American Academy of Family Physicians
• Insomnia at University of Maryland Medical Center

•  • [ e] WHO ICD-10 Mental and behavioural disorders (, )
Neurological/symptomatic	Dementia (Alzheimer's disease, Multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex) - Delirium - Post-concussion syndrome
Psychoactive substance	Intoxication (Drunkenness) - Physical dependence (Alcohol dependence, Opioid dependency) - Withdrawal (Benzodiazepine withdrawal, Delirium tremens) - Amnesic (Korsakoff's syndrome)
Psychotic disorder	Schizophrenia (Disorganized schizophrenia) - Schizotypal personality disorder - Delusional disorder - Folie deux - Schizoaffective disorder
Mood (affective)	Mania - Bipolar disorder - Clinical depression - Cyclothymia - Dysthymia
Neurotic, stress-related and somatoform	Agoraphobia - Anxiety disorder - Panic disorder - Generalized anxiety disorder - Social Anxiety Disorder - OCD - Acute stress reaction - PTSD - Adjustment disorder - Conversion disorder (Ganser syndrome) - Somatoform disorder - Somatization disorder - Neurasthenia
Physiological/physical behavioural	Eating disorder (Anorexia nervosa, Bulimia nervosa) - Sleep disorder (Dyssomnia, Insomnia, Hypersomnia, Parasomnia, Night terror, Nightmare) - Sexual dysfunction (Erectile dysfunction, Premature ejaculation, Vaginismus, Dyspareunia, Hypersexuality) - Postpartum depression
Adult personality and behaviour	Personality disorder - Passive-aggressive behavior - Kleptomania - Trichotillomania - Voyeurism - Factitious disorder - Munchausen syndrome
Mental retardation	Mental retardation
Psychological development (developmental disorder)	Specific: speech and language (Expressive language disorder, Aphasia, Expressive aphasia, Receptive aphasia, Landau-Kleffner syndrome, Lisp) - scholastic skills (Dyslexia, Dysgraphia, Gerstmann syndrome) - motor function (Developmental Dyspraxia) Pervasive: Autism - Rett syndrome - Asperger syndrome
Behavioural and emotional, childhood and adolescence onset	ADHD - Conduct disorder - Oppositional defiant disorder - Separation anxiety disorder - Selective mutism - Reactive attachment disorder - Tic disorder - Tourette syndrome - speech (Stuttering, Cluttering)

•  • [ e] Nervous system pathology, primarily CNS (, )
Inflammatory diseases of the CNS	Meningitis (Arachnoiditis) - Encephalitis - Myelitis - Encephalomyelitis (Acute disseminated) - Tropical spastic paraparesis
Systemic atrophies primarily affecting the CNS	Huntington's disease - Spinocerebellar ataxia (Friedreich's ataxia, Ataxia telangiectasia, Hereditary spastic paraplegia) Spinal muscular atrophy: Werdnig-Hoffman disease - Kugelberg-Welander disease - Fazio Londe syndrome - MND (Amyotrophic lateral sclerosis (ALS), Progressive muscular atrophy (PMA), Progressive bulbar, Pseudobulbar, PLS)
Extrapyramidal and movement disorders	Parkinson's disease - Neuroleptic malignant syndrome - Postencephalitic parkinsonism - Pantothenate kinase-associated neurodegeneration - Progressive supranuclear palsy - Striatonigral degeneration - Dystonia (Spasmodic torticollis, Meige's syndrome, Blepharospasm) - Essential tremor - Myoclonus - Chorea - Restless legs syndrome - Stiff person syndrome
Other degenerative / demyelinating diseases	Alzheimer's disease - Pick's disease - Alpers' disease - Dementia with Lewy bodies - Leigh's disease - Multiple sclerosis - Devic's disease - Central pontine myelinolysis - Transverse myelitis
Seizure/epilepsy	Focal (Simple partial, Complex partial) - Generalised (Tonic-clonic, Absence, Atonic, Benign familial neonatal) - Lennox-Gastaut - West - Epilepsia partialis continua - Status epilepticus (Complex partial status epilepticus)
Headache	Migraine (Familial hemiplegic) - Cluster - Vascular - Tension
Vascular	Transient ischemic attack (Amaurosis fugax, Transient global amnesia) - Cerebrovascular disease (MCA, ACA, PCA, Foville's syndrome, Millard-Gubler syndrome, Lateral medullary syndrome, Weber's syndrome, Lacunar stroke)
Sleep disorders	Insomnia - Hypersomnia - Sleep apnea (Ondine's curse) - Narcolepsy - Cataplexy - Kleine-Levin syndrome
Other	Hydrocephalus (Normal pressure) - Idiopathic intracranial hypertension - Encephalopathy - Brain herniation - Cerebral edema - Reye's syndrome - Syringomyelia - Syringobulbia - Spinal cord compression