1/05/2010 02:51:00 PM
Insomnia is a symptom of a sleeping disorder characterized by persistent difficulty falling asleep or staying asleep despite the opportunity. It is typically followed by functional impairment while awake. 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.
According to the U.S. Department of Health and Human Services in year 2007, approximately 64 million Americans suffer from insomnia each year. Insomnia occurs 1.4 times more commonly in women than in men.
Types of insomnia
Although there are several different degrees of insomnia, about 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.
2. Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.
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.
Patterns of insomnia
The pattern of insomnia often is related to the etiology.
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 syndromes or medical illness.
4. Terminal (or late) insomnia - early morning waking. Characteristic of clinical depression.
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 not significantly more than for antidepressants.Benzodiazepines did not have a significant tendency for more adverse drug reactions.
Benzodiazepines
Non-benzodiazepines
Nonbenzodiazepine prescription drugs, such as Ambien (zolpidem), Sonata (zopiclone) and Lunesta (eszopiclone), are more selective for the GABAA receptor 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 though less than traditional benzodiazepines, and can also cause the same memory and cognitive disturbances along with morning sedation. They belong to the new category of medications called sedative-hypnotics.
Antidepressants
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 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.
Melatonin
Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but there is little definitive data regarding its 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. 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
The antihistamine Benadryl (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 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.
Periactic (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.
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. Over time, Seroquel may lose its ability to produce sedation.
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. Cannabis has also been suggested as a very effective treatment for insomnia.
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 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.
Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal.
Cognitive behavior therapy
A recent study found that cognitive behavior therapy can be more effective than medication in controlling insomnia.In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep.
Complementary and alternative medicine
Some traditional and anecdotal remedies for insomnia include: drinking warm milk before bedtime, taking a warm bath, 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, going to bed at a reasonable hour and getting up early, and avoiding exposing the eyes to too much light, especially blue light, a few hours before bedtime. Initial treatment of insomnia may include the rules of sleep hygiene.
Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness. Many believe that listening to slow paced music will help insomniacs fall asleep.
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.
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.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,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. Binaural beats can help people fall asleep faster using special sounds.
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