Insomnia


The struggle for a good night's sleep

Every year, 30% of the people in the United States have problems getting to sleep or staying asleep. Insomnia affects everyone. In at least 50%, insomnia stems from psychological factors, such as anxiety or depression. Medical conditions, your lifestyle, inappropriate diet, using alcohol or drugs, travel, shift work, bereavement, and aging may all contribute to sleeping struggles. Some people need less sleep than others, and insomnia can only be diagnosed in relation to the individual experience and needs of each person.

Because of the wide variety of factors that can develop into sleeping problems, the best way to treat insomnia is on an individual basis, looking at the underlying issues and adapting to develop regular sleeping patterns. The use of hypnotic drugs, while effective in the short term, can have long-term adverse effects and should be used only as a last resort for treating insomnia.

Pronunciation

in-SOM-nee-uh

Synonyms

    • Sleeplessness

Detailed Description

Insomnia is not a condition unto itself. It is a symptom, a disturbance in sleep that could be due to many different causes. Most insomnia falls into four categories:

    • Sleep-onset insomnia (difficulty falling asleep)
    • Sleep-maintenance insomnia (frequent, sustained awakenings)
    • Sleep-offset insomnia (early morning awakenings)
    • Nonrestorative sleep (persistent sleepiness despite adequate duration of sleep)

Whatever its cause, insomnia is one of two types. Primary insomnia is a long-standing condition with little or no apparent relationship to any stress or life event. Secondary insomnia is connected directly to a condition or life event, and is due to physical pain, anxiety, medication, depression, or extreme stress.

Normal sleeping patterns

Brain-wave recordings have helped divide sleep into two broad states-- non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep has four distinct stages, starting with stage 1 (the lightest level when it is easy to wake) to stage 4 (the deepest level, during which waking is difficult). Stage 4 has several distinct physiological signs. Muscles are relaxed, blood pressure is at its lowest, and the heart and breathing slow down. REM sleep is the time when electrical activity in the brain is unusually high. When you dream, you are usually experiencing a REM sleep pattern. Sleep talking, sleep walking, and sleep terrors occur when you're in REM sleep and stages 3 or 4. Normally, REM sleep is cyclical, with several periods of NREM sleep following a period of REM sleep.

Sleeping patterns with insomnia

It is normal for older people to sleep less. As we age, stage 4 sleep becomes shorter and eventually disappears, and more awakenings occur during all stages. This shift in sleeping patterns can lead us to believe that we aren't getting enough sleep. There's no proof, however, that older people need as much sleep as younger people, or that sleep medications are needed to rectify a normal part of these age-related changes.

Disturbed patterns of sleep that are experienced with insomnia are not necessarily related to the aging process, however, and can occur at any age.

    • Sleep-onset insomnia is difficulty in falling asleep. This can be due to anxiety or tension, environmental changes or disruptions such as high altitude or travel, emotions, pain or discomfort, and consumption of caffeine or alcohol. The fear of not being able to get to sleep (fear of insomnia) and a phobia of sleep can also make falling asleep very difficult.
    • Sleep-maintenance insomnia is difficulty in staying asleep. It can be contributed to depression or emotional disturbance. Conditions such as hypoglycemia, sleep apnea, and restless leg syndrome can also lead to this pattern disruption. Environmental changes, pain or discomfort, and drugs and alcohol can also cause wakefulness after sleep has begun.
    • Sleep-offset insomnia, or early morning awakening, is a pattern that is more commonly experienced in elderly people, but could also be an indication of depression.
    • Nonrestorative sleep. Persistent sleepiness despite adequate duration of sleep.
    • Sleep rhythm reversal. This is the experience that occurs when your sleeping pattern has been disturbed, and it results in falling asleep at inappropriate times and being unable to fall asleep during normal evening hours. This sleeping pattern abnormality could be due to jet lag (especially when traveling from east to west), irregular work shifts, frequent changes in work hours, or excessive alcohol use. Sleep patterns can also be effected by medication, or by any kind of condition that might damage the brain's built-in clock, such as a stroke or Alzheimer's disease.

How Common Is Insomnia?

Over a third of the adult population has insomnia at some point and it is one of the most common complaints heard by primary care physicians. It affects all age groups, but older people seem to be the most affected. Women sufferer from insomnia at a higher rate than men.

What You Can Expect

Insomnia will usually resolve when the underlying cause is removed from your life. In other cases, it may resolve with time. Some types of insomnia without a readily treatable cause may persist. Bear in mind that not everyone needs eight hours of sleep-- for many, six to seven hours is adequate.

Established Causes

Insomnia has many causes. These psychological, biological, and lifestyle factors can all contribute to insomnia:

    • Painful and/or debilitating medical illnesses
    • Overactive thyroid gland (hyperthyroidism)
    • Any pulmonary or cardiac condition that causes difficulty in breathing
    • Sleep apnea (partial or total obstruction of airway during sleep)
    • Depression
    • Anxiety
    • Schizophrenia
    • Caffeine and other stimulants
    • Over-the-counter drugs such as cough suppressants or nasal decongestants
    • Multiple drug use
    • Jetlag due to traveling from different time zones
    • Hormonal changes in women
    • Genitourinary conditions that cause frequent urination
    • Neurologic disorders such as Parkinson's or Alzheimer's disease
    • Job shift change
    • Certain medications such as antidepressants
    • High altitude

Risk Factors

Some of these risk factors are correlated with increase in age, thus making insomnia more common among older people. Risk factors that may lead to insomnia include:

    • Chronic illness
    • Being more than 50 years old
    • Obesity
    • History of depression
    • Smoking
    • Being female

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

 

Symptoms

Signs and symptoms of insomnia usually involve any deviation from normal sleep pattern:

    • Difficulty in falling asleep at usual bedtime
    • Waking up in the middle of the night and unable to fall back to sleep
    • Waking up at unusually early hours (3 a.m. to 4 a.m.)
    • Sleepiness during daytime and sleeplessness during normal sleeping hours
    • Reduction in usual sleep time

Older people are more likely to suffer from insomnia, as they usually have many of the risk factors that contribute to it. External factors such as traveling, excessive caffeine or other stimulant intake, and caffeine intake at later hours (after 4 p.m.) can result in insomnia. Psychological issues such as stress, anxiety, fear, and depression may also contribute to insomnia. Examining your recent lifestyle may explain the occurrence of insomnia.

How Insomnia Is Diagnosed

Insomnia is usually identified by self-observation. Physician diagnosis generally involves a brief physical examination and a careful review of your medical history to pinpoint the cause(s). Obtaining a detailed sleep history is important. Items to note include the nature of the difficulty, factors that make it better or worse, sleep patterns, phenomena related to sleep, emotional factors, history of snoring, drug history, and general health. Sometimes the physician may suggest setting up an appointment with a sleep-study laboratory to get objective evaluation of the your sleep patterns.

Specific Tests

Specialized sleep studies including polysomnography are available for sleep apnea and other sleep disturbances.

Goals of Treatment

The goal of treating insomnia is to help you fall asleep easily, stay asleep throughout the night, and awaken refreshed.

Insomnia has no specific cure because it is due to numerous factors. Treatment, once the underlying cause of insomnia is identified, is individualized, allowing most individuals to reestablish normal sleeping patterns. Medications are sometimes used temporarily, but may produce adverse side effects in the long run. Sleep hygiene (see Insomnia: Self Care & Prevention) is important. Generally, insomnia should improve when its cause is identified and treated, although the most common cause, depression, is usually recurrent.

Treatment Overview

The goals of treatment vary according to the type of insomnia you are experiencing. A thorough review of your daily habits, drug intake, diet, and exercise pattern may uncover correctable causes of insomnia. For primary insomnia (a long-standing, chronic condition with no apparent relationship to any stress or life event), the treatment needs to address any medical or psychological issues that relate to the sleep disturbance.

Secondary insomnia is connected to a clear stress or life event, such as bereavement, medication, or depression. If the insomnia is transient (lasting less than four weeks), reassurance and supportive counseling are appropriate treatment options.

One of the most important measures in managing insomnia is attending to sleep hygiene. This includes:

    • Optimizing your bedroom for sleep
    • Keeping a regular sleeping schedule
    • Avoiding daytime napping
    • Avoiding heavy or spicy meals before bedtime
    • Avoiding caffeine, alcohol, and exercise in the evening
    • Seeking supportive counseling to help address the underlying causes of insomnia

Though hypnotic drugs are effective in inducing sleep, they can lose their effectiveness once your body becomes accustomed to them, and may produce withdrawal when discontinued. Furthermore, after only a few days of use, discontinuing the drug can make the original sleep problem worse (rebound insomnia) and increase anxiety.

The habit-forming potential of the benzodiazepine class of drugs is a long-term concern. These hypnotics work by suppressing brain functions. It can be particularly dangerous to get up-- say, to answer the phone or go to the bathroom-- in the hour after taking a hypnotic. They are also dangerous when taken with alcohol, other hypnotics, narcotics, antihistamines, and antidepressants. Overdose is possible with hypnotics. For these reasons, hypnotic drugs are not recommended for first-time treatment of insomnia.

Drug Therapy

Drugs Most Commonly Used

    • Antihistamines such as diphenhydramine (Benadryl)
    • Benzodiazepines such as Restoril (temazepam), Ativan (lorazepam), Halcion (triazolam), and Xanax (alprazolam)
    • Ambien (zolpidem)
    • Desyrel (trazodone), an antidepressant
    • Tricyclic antidepressants such as Elavil (amitriptyline)

Healthcare Professionals Who May Be Involved in Treatment

    • Internists
    • Pediatricians
    • Family physicians
    • Psychologists
    • Psychiatrists
    • Sleep medicine specialists
    • Pulmonologists
    • Otolaryngologists

Activity and Diet Recommendations

Restricting daily activities does not treat insomnia. A daily exercise routine, especially aerobic, helps as long as you don't exercise close to bedtime.

To help avoid insomnia you should avoid consuming:

    • Caffeine and related compounds. These are known to cause wakefulness. Caffeine isn't just found in coffee, but also in chocolate, soft drinks, tea, coffee-flavored ice cream, hot cocoa, and other foods. Even decaffeinated coffee contains some caffeine, and depending on your body's sensitivity to caffeine, this may be enough to cause insomnia.
    • Alcohol. Even though alcohol is a depressant, it produces a number of sleep-impairing effects. Alcohol can cause your body to release adrenaline, and it disrupts serotonin levels that help initiate sleep. If you do not eliminate alcohol from your diet completely, it should be avoided for at least three hours before retiring.

Quality of Life

Adequate sleep is restorative. It may be more difficult to recover from other medical conditions when you don't get sufficient sleep.

Considerations for Children and Adolescents

Insomnia affects children and adolescent less often than adults, but when it does, the problem must be addressed and treated to avoid further complications. Sleep-inducing drugs may be addictive and may result in adverse side effects. When a sleep-inducing drug is prescribed short-term by a physician, monitor your child's intake of the drug. Children are especially sensitive to stimulants. Children with insomnia should not take cough suppressants and use nasal decongestants that are known to cause excitability in children. Consider switching brands or to versions formulated for children. Adolescents typically need more sleep than adults.

Considerations for Older People

A shift in sleeping patterns as we age is normal, and the amount of sleep decreases as we get older. It is important to recognize this in addressing insomnia for the older people, and not to assume that less sleep is a problem unless it is causing distress in your daily activities.

Medication for insomnia in older people is started at lower doses. If increases in dosage are needed, they are done slowly.

Current Therapies Available

Generally, appropriate self care and removing or treating the cause of insomnia are most effective, but some sleep-inducing drugs are available for short-term use:

    • Benadryl (diphenhydramine)
    • Benzodiazepines such as Restoril (temazepam) and Ativan (lorazepam)
    • Ambien (zolpidem)
    • Desyrel (trazodone)
    • Tricyclic antidepressants such as Pamelor (nortriptyline).

Relaxation

    • Sleep experts recommend taking a hot bath an hour or so before your bedtime.
    • Buy some relaxation tapes or CDs. Soothing, restful music can help ease you into sleep.
    • Try meditating. In a 1996 report, investigators with the National Institutes of Health concluded that relaxation therapies -- especially meditation -- show significant benefit in treating insomnia. [1]
    • Biofeedback may help. This relaxation technique trains you to control automatic body functions, like heartbeat, that you might not think could be voluntarily controlled. The same NIH panel that endorsed meditation also endorsed biofeedback training as a sleep aid. [2]

Supplements

Melatonin is a hormone secreted by the pineal gland and involved in regulating sleep-wake cycles. Melatonin levels are generally higher at night and lower during the day. In one, researchers asked a dozen healthy young volunteers to try to nap from 6 p.m. to 8 p.m. Compared with those who took a placebo, participants who took 3 mg of melatonin 30 to 90 minutes before laying down fell asleep significantly faster and slept more soundly.[3]

More recent studies have been less conclusive about its effectiveness.

Sleep experts generally recommend 0.5 to 3 mg of melatonin one to two hours before bedtime.

Melatonin should not be used by women who are pregnant, breastfeeding, or considering getting pregnant. If you have any chronic medical condition, consult a physician before taking melatonin.

Herbs

    • Valerian: This is the herbal sedative of choice. Many studies show that it relieves insomnia. For example: Swedish researchers gave either a placebo or valerian to a large group of insomniacs. The placebo group reported negligible improvement in sleep, but 89% of the valerian group said the herb helped them sleep better. 
    • Chamomile: Along with catnip and other popular "relaxation" herbs, chamomile acts as a gentle sedative. Use two teaspoons of herb per cup of boiled water. Steep 10 minutes and enjoy.

1, 2 NIH Technology Assessment Panel. "Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia," Journal of the American Medical Association 276:313, 1996.

3 Nave, R., et al. "Melatonin Improves Evening Napping," European Journal of Pharmacology 275:213, 1995.

4 Lindhal, O. "Double-Blind Study of a Valerian Preparation for Insomnia," Pharmacology, Biochemistry, and Behavior 32:1065, 1989.

Preventing Insomnia

Because of the connection between psychological disturbance and insomnia, one of the best ways to prevent sleeping problems is to establish a lifestyle that fosters healthy sleep patterns. This includes an active, fulfilling, regularly scheduled daily life. Time for relaxation and healthy, nonstimulating foods are part of prevention. Seeking ways to minimize stress is imperative to insomnia prevention.

If you're experiencing stress that causes trouble sleeping, counseling and environmental support can prevent recurring problems. Adapting diet and work pressures to allow time for relaxation is essential for stopping insomnia relapses.

Self-Care Measures

Here are some self-care methods for reducing insomnia. You don't have to follow all of them -- just the ones you think might help most. If they don't work, try some of the others. Through trial and error, you might find that one or two of these measures will help you get that good night's sleep.

    • Get comfortable. Make sure your mattress, pillows, and linens are cozy enough to promote sound sleep.
    • Keep your bedroom quiet. If you can't control a source of outside noise, earplugs can make a big difference in the quality of your sleep.
    • Keep your bedroom dark. As you age, it's easier for light to disrupt your sleep. Use heavy drapes, blinds, or shades on your windows, or wear a sleep mask.
    • Establish regular sleep habits. Go to bed and wake up at the same time every day, even on weekends. A regular sleep/wake rhythm helps many people fall asleep and stay asleep. Don't nap.
    • Unwind with bedtime routines. Before-bed rituals -- drinking a glass of milk or a cup of herbal tea, or reading a book -- help you make the transition from waking to sleeping.
    • Let go of tomorrow. Rather than tossing and turning because you have to remember so many things for tomorrow, jot them down, then let go of them until you wake up.
    • Consider getting a bigger bed. If you wake up when your bedmate rolls over, you need more room.
    • Consume less caffeine. Try tapering off caffeinated coffee, tea, and sodas. You might be amazed at how much more soundly you sleep. Just don't cut out all caffeine suddenly or you may suffer a withdrawal headache that might keep you awake.
    • Keep bedtime snacks light. Fatty, greasy foods are hard to digest and might keep you up. You'll probably sleep better if you limit late-night snacks to fruits or herb teas.
    • Exercise regularly. It has a tiring effect. Sleep experts generally recommend daily 30- to 60-minute brisk walks. Just don't exercise within a few hours of your bedtime or you might not be able to fall asleep.
    • If you smoke, quit. Nicotine is a powerful stimulant.

The six-step behavior program

This behavior-therapy program was developed in the 1970s by Richard Bootzin, Ph.D., of Northwestern University. Many sleep experts recommend it.

    • Go to bed only when you feel sleepy. Forget the clock.
    • Use your bed only for sleeping and sex. Don't read, eat, watch TV, or talk on the phone while you're in bed.
    • If you go to bed but can't fall asleep, get up and leave the bedroom. Amuse yourself until you feel sleepy, then return to bed.
    • Repeat Step 3 as often as necessary throughout the night.
    • No matter what time you go to sleep, set an alarm for the same time every morning.
    • Don't nap.

 

Websites & Organizations

American Academy of Family Physicians Foundation
P.O. Box 8418
Kansas City, MO 64114
Phone: 800-274-2237, ext. 4400

American Narcolepsy Association
P.O. Box 1187
San Carlos, CA 94070

American Sleep Disorders Association
1610 14th Street NW, Suite 300
Rochester, MN 55901
Phone: 507-287-6006

Association of Professional Sleep Societies
604 2nd St.
SW Rochester, MN 55902

Doctor's Guide to Insomnia Information and Resources

National School of Sleep Medicine

National Sleep Foundation
1357 Connecticut Avenue NW
Washington, DC 20036
Phone: 202-785-2300

Shuteye Online

SleepMultimedia Inc.
Phone: 914-722-9291
Fax: 914-722-4490

UCSF/Stanford Sleep Disorders Center
University of California, San Francisco
1600 Divisadero Street
San Francisco, CA 94115
David M. Claman, M.D.
Phone: 415-885-7886
Fax: 415-885-3650

Sources for This Article

Books

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Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W. B. Saunders, 1996.

Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.



Articles

Bliwise, DL. "Treating Insomnia: Pharmacological and Nonpharmacological Approaches." J Psychoactive Drugs. 23(4):335-41. Oct-Dec 1991.

Czeisler, CA, Richardson, GS. "Detection and Assessment of Insomnia." Clin Ther. 13(6):663-79; discussion 662. Nov-Dec 1991.

Hauri, PJ, Esther, MS. "Insomnia." Mayo Clin Proc. 65(6):869-82. Jun 1990.

Maczaj, M, "Pharmacological Treatment of Insomnia." Drugs. 45(1):44-55. Jan 1993.

Mahendran, R. "Management of Insomnia." Singapore Med J. 36(1):80-3. Feb 1995.

Morin, CM, Culbert, JP, Schwartz, SM. "Nonpharmacological Interventions for Insomnia: A Meta-analysis of Treatment Efficacy." Am J Psychiatry. 151(8):1172-80. Aug 1994.

Nino-Murcia, G. "Diagnosis and Treatment of Insomnia and Risks Associated with Lack of Treatment." J Clin Psychiatry. 53 Suppl():43-7; discussion 48-9. Dec 1992.

Nowell, PD, Buysse, DJ, Reynolds, CF 3rd, Hauri, PJ, Roth, T, Stepanski, EJ, Thorpy, MJ, Bixler, E, Kales, A, Manfredi, RL, Vgontzas, AN, Stapf, DM, Houck, PR, Kupfer, DJ. "Clinical Factors Contributing to the Differential Diagnosis of Primary Insomnia and Insomnia Related to Mental Disorders." Am J Psychiatry. 154(10):1412-6. Oct 1997.

Spielman, AJ, Nunes, J, Glovinsky, PB. "Insomnia." Neurol Clin. 14(3):513-43. Aug 1996.

Wagner, J, Wagner, ML, Hening, WA. "Beyond Benzodiazepines: Alternative Pharmacologic Agents for the Treatment of Insomnia." Ann Pharmacother. 32(6):680-91. Jun 1998.

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