Insomnia

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. <http://www.asda.org>.

National Sleep Foundation. 1522 K St. NW, Suite 510, Washington, DC 20005. <http://www.sleepfoundation.org>.

OTHER

"Acupuncture and Insomnia." Alternative Medicine Update (October 1999). <http://www.healthmall.com>.

"Insomnia." CBS Health Watch. <http://www.cbshealthwatch.com>.

"Patient Information: Insomnia and What You Can Do to Sleep Better." American Family Physician. 49, no. 6 (May 1, 1994). <http://srvr.third-wave.com/tricounty/insomnia.html> (1998).

"Sleep Aids: Everything You Wanted to Know…But Were Too Tired to Ask." National Sleep Foundation, 1999. <http://www.sleepfoundation.org/publications/sleepaids.html>.

"What to Do When You Can't Sleep." Children's Hospital of Iowa. 1995. <http://www.vh.org/Patients/IHB/FamilyPractice/AFP/January1995/Insomnia.html> (1998).

Willard, Terry. "Insomnia: Wake up to ten simple solutions." Herbs for Health. HealthWorld Online. <http://www.healthy.net/hfh/articlesHFH/sleep.htm>.

Liz Swain

Insomnia

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Resources

Definition

Insomnia is a condition that occurs when a person in unable to get long enough or refreshing enough sleep at night. An inability to fall asleep, an inability to stay asleep, or waking too early before having gotten enough sleep are all forms of insomnia

Description

Insomnia is a disorder in which people are unable to get enough, or enough restorative, sleep because of one or more factors. People with insomnia often have daytime symptoms related to a lack of sleep, such as daytime sleepiness, fatigue , and decreased mental clarity.

There are two main types of insomnia. One is acute insomnia (sometimes called transient insomnia). This type occurs when insomnia symptoms exist over a reasonably short period of time. The other type is chronic insomnia, which is diagnosed when the symptoms manifest themselves over a longer period (generally more than one month). Insomnia can also be classified as either primary or secondary. Primary insomnia is a disorder that cannot be attributed to another condition or disorder. Secondary insomnia can be traced back to a source, which may be a medical condition; the use of medications, alcohol, or other substances; or a mental disorder such as severe depression.

Not all disruptions in the normal pattern of sleeping and waking are considered insomnia. Such factors as jet lag, unusually high levels of stress , changing work shifts, or other drastic changes in the person’s routine can all lead to sleep problems. Unless the problems are ongoing and severe enough that they are causing distress for the person in important areas of life, he or she is not considered to have insomnia.

Causes and symptoms

The symptoms of insomnia can vary greatly from person to person. Some people find that they have trouble falling asleep at night and can lie in bed for hours without being able to drift off. Others find that they fall asleep easily, but wake many times during the night. Other people awaken too early in the morning and are then unable to get back to sleep. Some people even get enough hours of sleep but find that they do not feel rested, often because their sleep is too light.

Not all people experiencing insomnia have symptoms that occur during the daytime, but many do. Some people experience such symptoms as reduced ability to concentrate or pay attention, decreased alertness, and mental sluggishness. Some people have trouble staying awake. More people think that they have these symptoms than actually do. Upon clinical examination, many people who think that they are excessively sleepy during the day actually are not.

Many different things are thought to cause or contribute to insomnia. Stressors, such as starting a new job, or changes in routine, such as beginning to work a different shift, can lead to temporary sleep problems. Sleep problems can become aggravated and persist after the worry or change causing the sleep problem has been resolved. This persistence is thought to be related to the anxiety created by attempting to go to sleep and not expecting to fall asleep. Anxiety about sleep loss can lead to a vicious circle in which the person has more and more concern about being able to fall asleep, making it increasingly difficult to do so. Some people even report that they are better able to fall asleep when they are not in their beds. This relative success is thought to occur because the new environment is not associated with the fear and anxiety of not being able to sleep, therefore making it easier to fall asleep.

Many other factors are thought to lead to or perpetuate insomnia. These include drinking tea or coffee, eating a large meal, taking certain medications or drugs of abuse (cocaine, amphetamines) that have a stimulating effect, or exercising heavily in the hours before attempting to sleep. Also, attempting to sleep in a room with too much light or noise can make it harder for some people to sleep. Doing activities in bed that are not associated with sleep, such as reading or watching television, can make it more difficult for some people to fall asleep when they finally want to. Sleep may be even more difficult if the television show or book was frightening or upsetting.

Demographics

There are many different opinions about how much of the general American population experiences insomnia. Estimates suggest that around 5-20% of the adult population suffers from some form of insomnia or long-term sleeping problem. Nearly half report at least occasional sleeping problems. Accurate data is difficult to gather, as many people misperceive how much sleep they actually get and how many times they normally wake up during the night. It is generally agreed, however, that women are more likely than men to suffer from insomnia. As people get older, they are also are more likely to experience insomnia. People who are nervous or tense are more likely to have insomnia than those who are not. Lastly, people who live near airports or other sources of nighttime as well as daytime noise have higher rates of insomnia than the general population.

Diagnosis

According to the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR), which presents the guidelines used by the American Psychiatric Association for diagnosis of disorders, in order to be diagnosed with primary insomnia, a person must experience the symptoms for at least a month, and the symptoms must cause them distress or reduce their ability to function successfully. The symptoms cannot be caused by a different sleep disorder, a medical condition, or be a side effect of medications or substance abuse.

Insomnia may also be comorbid with (occur together with) other psychiatric disorders, including mania, depression, and the anxiety disorders.

Insomnia is a disorder that is usually self-reported; that is, patients usually bring up the subject of sleep problems with their doctors rather than the doctor suggesting the diagnosis. There are no laboratory tests for insomnia, but the doctor may suggest keeping a sleep diary, in which the patient notes the time they went to bed, the time (s) at which they got up during the night, their activities before bed, etc. Sleep diaries can be helpful in uncovering specific factors related to the insomnia.

Treatments

Many treatments have been explored for treating insomnia in a number of different settings. The patient may wish to consider consulting a sleep clinic or a doctor who specializes in the treatment of sleep disorders as well as their family doctor.

Behavioral and educational therapies are usually tried first, because they do not have side effects and cannot create a chemical dependence the way some sleep medications can. Many different approaches have been designed to help patients whose insomnia is linked to particular factors.

Behavioral treatments

One common behavioral therapy involves changing any pre-bedtime activities or behaviors that might interfere with sleep. Avoiding large meals, alcohol or caffeinated beverages, or intensive exercise in the hours before bedtime may help the patient to fall asleep.

Another non-medicinal treatment for insomnia involves controlling the patient’s mental associations with the bedroom. The patient is trained to associate the bed only with sleep, not with the frustration of trying to fall asleep or with such waking activities as reading or watching television. As part of this training, if the patient cannot sleep after a certain amount of time, he or she is instructed to get out of bed and spend time somewhere else in the house doing an activity that they find relaxing. The patient lies down again only when sleepy. This technique helps to prevent frustration from trying to sleep.

Another common technique that does not involve medication is sleep restriction therapy. During this therapy, the amount of time that patients are allowed to spend in bed is limited to only slightly more time than they believe that they already sleep at night. Gradually the amount of time patients are allowed to spend in bed is increased until they are getting a full night’s sleep. Unfortunately, many people find this treatment difficult to stick with, because they often become mildly sleep-deprived. The resultant fatigue can be useful, however, as it may help them fall asleep more easily and to stay asleep longer at night.

Teaching relaxation techniques that help patients concentrate on relaxing thoughts or images can also help patients experiencing insomnia. Most of these therapies also include setting times for waking and having the patient stick to them even if he or she has not gotten a full night of sleep. The elimination of all daytime napping can help to facilitate sleep at night. These treatments are effective by themselves, but may also be combined with other approaches. The course of treatment depends on the patient’s specific symptoms.

Treatment with medications

Many different medicines, which are called hypnotics, are used to treat insomnia. These are usually not recommended for use for longer than a week because they may cause dependence. In addition, there is always the risk of side effects. There are many different types of hypnotics, and choosing one for a patient depends on the patient’s symptoms, other drugs that he or she may be taking, any medical or psychological conditions, and other health factors. Medication treatment is best used in coordination with a behavioral therapy program.

KEY TERMS

Hypnotic —A type of medication that induces sleep.

Recently, two drugs have been approved by the US Food and Drug Administration for long-term use. A drug called ramelteon (brand name Rozerem) has shown no evidence of potential for abuse, dependence or withdrawal in clinical studies. Eszopiclone (brand name Lunesta) is also approved for long-term use. Rozerem and Lunesta are currently available by prescription only.

Alternative remedies

Alternative remedies for insomnia, particularly herbal preparations, should be mentioned because they are among the most popular nonprescription treatments for sleep problems. According to Prevention magazine, insomnia is the sixth most common condition treated with herbal formulas in the United States; it accounts for 18% of all use of herbal preparations. Some herbs used for insomnia are safer than others. Persons who are using alternative remedies, whether to treat insomnia or other conditions, should always tell their doctor what they are taking, how much, and how often. This warning is important because some herbal preparations that are safe in themselves can interact with prescription medications.

Prognosis

Untreated insomnia has potentially serious consequences, including an increased risk of motor vehicle accidents, impaired school or job performance, and a high rate of absenteeism from work. Fortunately, insomnia can be treated very effectively in most patients. Treatment using a combination of approaches is usually most effective. Patients who have had insomnia once are at an increased risk for recurrent insomnia.

See alsoCaffeine-related disorders; Chamomile; Passionflower; Valerian.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.

Currie, Shawn R. “Sleep Dysfunction.” Clinicians’s Handbook of Adult Behavioral Assessment, Ed. Michel Hersen. San Diego, CA: Elsevier Academic Press, 2006: 401–430.

Lee-Chiong, Teofilo L. Ed. Sleep: A Comprehensive Handbook. New York: Wiley-Liss, 2006.

Neubauer, David N. Understanding Sleeplessness: Perspectives on Insomnia. Baltimore: The Johns Hopkins University Press, 2003.

Pelletier, Kenneth R. The Best Alternative Medicine. New York: Simon and Schuster, 2002.

Spinella, Marcello. Concise Handbook of Psychoactive Herbs: Medicinal Herbs for Treating Psychological and Neurological Problems. New York: The Haworth Herbal Press, 2005.

Szuba, Martin P., Kloss, Jacqueline D., and Dinges, David F., eds. Insomnia: Principles and Management. New York: Cambridge University Press, 2003.

PERIODICALS

Irwin, Michael R. and Cole, Jason C. “Comparative Meta-Analysis of Behavioral Interventions for Insomnia and Their Efficacy in Middle-Aged Adults and in Older Adults 55+ Years of Age.” Health Psychology, 25(1), Jan 2006: 3–14.

Jansson, Markus and Linton, Steven J. “The Role of Anxiety and Depression in the Development of Insomnia: Cross-Sectional and Prospective Analyses.” Psychology and Health, 21(3), Jun 2006: 383–397.

Jansson, Markus and Linton, Steven J. “Psychosocial Work Stressors in the Development and Maintenance of Insomnia: A Prospective Study.” Journal of Occupational Health Psychology, 11(3), Jul 2006: 241–248.

Manber, Rachel and Harvey, Allison. “Historical Perspective and Future Directions in Cognitive Behavioral Therapy for Insomnia and Behavioral Sleep Medicine.” Clinical Psychology Review, 25(5), Jul 2005: 535–538.

Smith, Michael T. and Perlis, Michael L. “Who Is a Candidate for Cognitive-Behavioral Therapy for Insomnia?” Health Psychology, 25(1), Jan 2006: 15–19.

ORGANIZATIONS

American Academy of Sleep Medicine. 6301 Bandel Road NW, Suite 101, Rochester, MN 55901. (507) 287-6006. <www.asda.org>.

Tish Davidson, A.M.
Ruth A. Wienclaw, Ph.D.

Insomnia

Definition

Insomnia is a consistent lack of ability to sleep at the time when sleep should normally occur. It is usually a symptom of another underlying condition rather than a single, separate condition.

Description

Insomnia, or inability to sleep, can occur as difficulty getting to sleep, periods of restless sleep, or being completely awake during normal nighttime sleeping hours for some period of time. It can result in loss of energy and changes in mood. Insomnia can be either a temporary or acute condition, or can become chronic. While any individual may experience disturbed sleep occasionally, it is not considered to be insomnia unless it occurs consistently over a period of time. For optimum energy and functioning during each day, healthy adults are advised to have about eight hours of sleep each night. The need for sleep will vary among individuals, some requiring less than eight hours and others needing more hours. However, as people age and daytime activity is reduced, it is normal for changes to occur in the total hours of sleep required. These changes do not necessarily include insomnia, which refers specifically to inability to go to sleep when first getting into bed, or waking during the night and not being able to go back to sleep. Chronic insomnia, while not dangerous, can lead to reduced energy and physical performance and reduced interaction with others, sometimes interfering with close personal relationships and overall behavior.

Demographics

Approximately 30–50% of the population has some form of insomnia; about 10% have chronic insomnia. Although insomnia affects people of all ages, the incidence of insomnia increases with age and occurs more in women than in men.

Causes and symptoms

Insomnia is usually a symptom of an underlying condition or lifestyle factors and not a condition on its own. It can be caused by a broad range of physical, psychological and lifestyle conditions, including indigestion, difficulty breathing, muscle aches, pain, anxiety, stress, depression , use of caffeine or alcohol, use of nicotine, low blood sugar (hypoglycemia), and use of certain medications (e.g., anti-depressants, cold and asthma medicines that contain stimulants, thyroid drugs, blood pressure and heart medications). Stress is the most common cause of short-term insomnia. Chronic insomnia develops when underlying causes of insomnia are not addressed. Lack of sufficient exercise during the day may result in sleepless nights. Poor eating habits may also disturb sleep, such as consuming sugary or fatty foods close to bedtime or going to bed immediately after eating a large meal. Deficiencies in certain vitamins and nutrients can affect sleep, especially reduced levels of calcium and magnesium, natural relaxants for the body. Nutrients can be reduced by fluid losses (dehydration ) associated with drinking caffeinated or alcoholic beverages in the evening before sleep.

The presence of certain systemic disorders can also cause sleeplessness, particularly disorders of the digestive system (GERD), lungs (COPD), congestive heart failure , diseases of the pancreas and liver, and Alzheimer's disease. Restless leg syndrome, a condition affecting millions of individuals, and cramping of leg muscles can interrupt sleep, eventually resulting in insomnia when the individual comes to expect the leg conditions to develop. Sleep apnea, a serious breathing disorder, reduces the individual's oxygen levels and may cause sudden waking many times a night, resulting in overall lack of sleep or insomnia. Conditions that produce pain such as osteoarthritis , rheumatoid arthritis , or fibromyalgia and nerve disorders may disturb sleep, resulting in insomnia if not treated.

Symptoms of insomnia can be physical or mental. The most common complaint is difficulty falling asleep, often associated with stress and stressful thoughts. Depression may occur along with insomnia. Continued insomnia and reduced overall sleep may result in reduced ability to concentrate, memory failure, reduced motor skills, irritability and reduced social contact, frequent accidents, and dependence on sleep aids.

Diagnosis

A physician should be consulted if sleep problems last more than a month. The physician will want to determine overall health condition to help determine what is causing sleeplessness. A thorough health history will be taken, including prior illnesses, surgeries and medications, current conditions for which the individual is being treated and all medications being taken, including over-the-counter medications. The doctor will ask about sleep habits and possible snoring. Blood pressure and heart rate will be measured. Laboratory tests may be done to evaluate overall health, including presence of anemia , diabetes, kidney or liver disease, and thyroid disease. Breathing will be evaluated and the nose will be examined for possible blockage of nasal passages. Mental health may be evaluated if symptoms of anxiety or depression are noticed. For some individuals, a sleep test (polysomnogram) may be performed. Individuals who snore may be evaluated for sleep apnea. Some individuals with sleep disorders may be referred to a sleep disorder center where sleep is studied thoroughly before recommendations are made and specific therapies applied to help the individual restore sleep habits.

Treatment

The goal of treatment for insomnia is to improve sleep habits and modify any factors that have negative effects on sleep. The sleep environment may be corrected to improve sleep conditions and promote better sleep. Behavior, diet and lifestyle modifications may be recommended to address eating and drinking habits. Medications may be prescribed to treat stress or to promote sleep (e.g., eszopiclone, zalplon, zolpidem). Melatonin, a natural substance produced in the body to regulate sleep, may be recommended as a supplement since levels decrease with age, or a drug (ramelteon) that encourages melatonin production by the body may be prescribed. Relaxation techniques may be recommended for some individuals as well as an exercise program to increase daily activity levels.

Sleep apnea requires specific treatment that may include allergy medications, reducing weight, or having surgery to remove excess cartilage from the passageways of the nose. Restless leg syndrome may require vitamin or mineral supplementation and balancing electrolytes in the blood such as calcium/magnesium and sodium/potassium.

Sleeping medications are often used but it should be acknowledged that they do not cure insomnia, offering only increased hours of sleep while sometimes interfering with deeper levels of sleep such as rapid eye movement (REM) sleep, actually increasing the overall sleep disturbance. The use of sleeping medications includes cautions. Twice as many people who take sleep medicines are involved in accidents such as automobile accidents and work-related accidents. Prescribed sleep medications (e.g., triazolam, temazepam, flurazepam, and diazepam) can produce confusion, restlessness, anxiety and drug dependency. Newer drugs (e.g., eszopiclone, zalplon, zolpidem) have fewer side effects but can cross-react with other medications such as antidepressants or blood pressure medications. Taking over-the-counter sleeping remedies can result in agitation or anxiety, confusion, depression and dehydration. Always consult a physician before taking sleep medications and follow directions exactly.

QUESTIONS TO ASK YOUR DOCTOR

• Why can't I sleep through the night?
• What can I do to help get to sleep and prevent waking up during the night?
• Is it alright for me to take sleeping pills?
• Will I be able to enjoy sleep again?
• How many people regain normal sleep and how do they do it?

Nutrition/Dietetic concerns

Calcium and magnesium are recommended as nutritional supplements because of their calming effects. Because these essential nutrients must be in balance with each other, they should be taken together daily with a meal. Supplemental B vitamin complex is also recommended to help relieve stress and achieve a restful state. Caffeine and alcohol should be avoided. Relaxing teas containing chamomile and/or catnip (catmint) can be consumed before bed. Herbal tinctures such as skullcap, passionflower, hops, kava kava, or valerian root are considered nerviness and are known to calm the nervous system and promote restful sleep. A natural hormone produced by the body, dehydroepisterone (DHEA ), is reduced in older individuals and has been shown to improve sleep when taken as a supplement. It is available in whole food stores and in some pharmacies.

Therapy

Massage therapy encourages relaxation by relaxing tense muscles throughout the body. It is especially helpful for restless leg syndrome, when this is a cause of insomnia. A massage once a week by a registered massage therapist may help the individual relieve stress that is causing sleeplessness.

Prognosis

Insomnia is more of a disturbance than a condition, and is more annoying than it is harmful. It can be prevented or corrected in most adults, although in some cases an underlying illness will require treatment in order to correct related insomnia. Sleep apnea is a potentially serious disorder related to breathing difficulties and chronic lung conditions; it can be fatal if not treated.

KEY TERMS

COPD (chronic obstructive pulmonary disorder) —Lung diseases that involve narrowing of the small bronchi resulting in reduced expiration of air such as emphysema.

GERD (gastroesophageal reflux disease) —Chronic or recurrent upward movement of gastric juices from the stomach into the lower esophagus, producing pain, belching, nausea and cough and sometimes causing regurgitation of stomach contents into the esophagus.

Polysomnogram —A sleep study that measures sleep cycles by evaluating eye movements, heart rate, breathing rate, brain waves, electrical activity of the muscles, and levels of blood oxygen.

Sleep apnea —Cessation of breathing during sleep often accompanied by frequent waking during the night and sleepiness during the day.

Prevention

Adopting certain lifestyle habits may help promote restful sleep and prevent insomnia, including the following recommendations:

• Avoid smoking tobacco and consuming alcohol.
• Avoid or reduce caffeine consumption.
• Allow two hours between the evening meal and bedtime. Avoid eating salty, sugary or fatty foods close to bedtime
• Exercise regularly during the day.
• Reserve the bedroom for sleeping. Watch TV in another room and avoid disturbing programs before bedtime, such as those with violent or frightening content.
• When going to bed, focus on regular breathing rather than on thoughts or worries. Learn a relaxation technique or meditation method and practice it regularly.
• Keep the sleeping room at a comfortable temperature—not too hot or cold. Open a window just enough to allow fresh air to circulate.
• Take a warm bath or shower before bed.
• Get up at the same time every morning regardless of how many hours of sleep were gained. If accustomed to napping, it's alright to continue.

Caregiver concerns

An individual who is not enjoying regular sleep may become anxious, depressed or irritable during the day, and may also fall asleep for long periods, preventing sleep at night. The caregiver can encourage movement and exercise during the day, which will help the individual gain a good night's sleep. The evening meal should be served early enough to allow two hours for digestion before trying to go to sleep. If the individual is taking sleeping medication, dosage should be checked by the caregiver to avoid overdosing. Activities during the day should be carefully supervised to prevent accidents caused by inattention or drowsiness.

Resources

BOOKS

Balch, P.A. “Insomnia.” Prescription for Nutritional Healing. Garden City Park, NY: Avery, 1997.

WEBSITES

“Insomnia.” Insomnia Causes, Symptoms, Diagnosis, Treatment and Prevention. eMedicine Health. WebMD 2007. Available at www.emedicinehealth.com. Accessed March 10, 2008.

“Insomnia.” Mayo Foundation for Medical Education and Research. Mayo Clinic, 2007. Available at www.Mayoclinic.com/health/insomnia/DS00187. Accessed March 10, 2008.

ORGANIZATIONS

National Sleep Foundation, 1522 K Street, NW, Suite 500, Washington, DC, 20005, 202-347-3471, nsf@sleep-foundation.org, www.sleepfoundation.org.

American Academy of Sleep Medicine, One Westbrook Corporate Center, suite 920, Westchester, IL, 60154, 708-492-0930, American Sleep Association, 614 South 8th Street, Suire 282, Philadelphia, PA, 19147, 443-593-2285, sleep@1sleep.com

L. Lee Culvert

Insomnia

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 with 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.

Causes and 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.

Chronic insomnia usually has different causes, and there may be more than one. These include:

• A medical condition or its treatment, including sleep apnea
• Use of substances such as caffeine, alcohol, and nicotine
• Psychiatric conditions such as mood or anxiety disorders
• Stress, 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 go to sleep, which creates so much anxiety that the individual's bedtime rituals and behavior actually trigger insomnia. The more one worries about falling asleep, the harder it becomes. 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 in 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

The diagnosis of insomnia is made by a physician based on the patient's reported signs and symptoms. It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, 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, 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

Treatment of insomnia includes alleviating any physical and emotional problems that are contributing to the condition and exploring 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 their insomnia. They should go to bed only when sleepy and use the bedroom only for sleep. Other activities like reading, watching television, or snacking should take place somewhere else. If they are unable to go to sleep, they should go into another room and do something that is relaxing, like reading. Watching television should be avoided because it has an arousing effect. The person should return to bed only when they feel 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 sleep-wake 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, which restricts the amount of time spent 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 is sleeping five hours a night, the time in bed is limited to 5-5 1/2 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.

Drug therapy

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 two to four times daily for approximately three to four weeks, though this will vary with the physician and patient. If the insomnia is related to depression, then an antidepressant medication may be helpful. Over-the-counter drugs such as antihistamines are not very effective in bringing about sleep and can affect the quality of sleep.

Other measures

Relaxing before going to bed will help a person fall asleep faster. Learning to substitute pleasant thoughts for unpleasant ones (imagery training) is a technique that can be very helpful in reducing worry. Another effective measure is the use of audiotapes which combine the sounds of nature with soft relaxing music. These, alone or in combination with other relaxation techniques, can safely promote sleepiness.

Changes in diet and exercise routines can also have a have a beneficial effect. Dietary items to be avoided include 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. Maintaining a comfortable bedroom temperature, reducing noise and eliminating light are also helpful. Regularly scheduled morning or afternoon exercise can relax the body. This should be done 3-4 times a week and be sufficient to produce a light sweat.

Alternative treatments

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Incorporating relaxation techniques into bedtime rituals will help a person go to sleep faster, as well as improve the quality of sleep. These methods include meditation, massage, breathing exercises, and a warm bath, scented with rose, lavender (Lavendula officinalis ), marjoram, or chamomile (Matricaria recutita ). 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, or a cup of herb tea made with chamomile, hops (Humulus lupulus ), passionflower (Passiflora incarnata ), or St John's Wort (Hypericum perforatum ) to encourage relaxation. Acupuncture and biofeedback have also proven useful.

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.

Resources

ORGANIZATIONS

American Sleep Disorders Association. 1610 14th St. NW, Ste. 300, Rochester, MN 55901. (507) 287-6006. 〈http://www.asda.org〉.

OTHER

"What to Do When You Can't Sleep." The Virtual Hospital Page. University of Iowa. 〈http://www.vh.org〉.

KEY TERMS

Biofeedback— A training technique that enables an individual to gain some element of control over involuntary body functions.

Mood disorder— A group of mental disorders involving a disturbance of mood, along with either a full or partial excesseively happy (manic) or extremely sad (depressive) syndrome not caused by any other physical or mental disorder. Mood refers to a prolonged emotion.

Sleep apnea— A condition in which a person stops breathing while asleep. These periods can last up to a minute or more, and can occur many times each hour. In order to start breathing again, the person must become semi-awake. The episodes are not remembered, but the following day the client feels tired and sleepy. If severe, sleep apnea can cause other medical problems.

Sleep disorder— Any condition that interferes with sleep. At least 84 have been identified, according to the American Sleep Disorders Association.

Insomnia

Definition

Insomnia is a condition that occurs when a person in unable to get long enough or refreshing enough sleep at night. Insomnia can result from an inability to fall asleep, an inability to stay asleep, or waking too early before having gotten enough sleep.

Description

Insomnia is a disorder in which people are unable to get enough, or enough restorative, sleep because of one or more factors. People with insomnia often have daytime symptoms related to a lack of sleep, such as daytime sleepiness, fatigue , and decreased mental clarity.

There are two main types of insomnia. One is acute insomnia (sometimes called transient insomnia). This type occurs when insomnia symptoms exist over a reasonably short period of time. The other type is chronic insomnia, which is diagnosed when the symptoms manifest themselves over a longer period (generally more than one month). Insomnia can also be classified as either primary or secondary. Primary insomnia is a disorder that cannot be attributed to another condition or disorder. Secondary insomnia can be traced back to a source, which may be a medical condition; the use of medications, alcohol, or other substances; or a mental disorder such as severe depression.

Not all disruptions in the normal pattern of sleeping and waking are considered insomnia. Such factors as jet lag, unusually high levels of stress , changing work shifts, or other drastic changes in the person's routine can all lead to sleep problems. Unless the problems are ongoing and severe enough that they are causing distress for the person in important areas of life, he or she is not considered to have insomnia.

Causes and symptoms

The symptoms of insomnia can vary greatly from person to person. Some people find that they have trouble falling asleep at night and can lie in bed for hours without being able to drift off. Others find that they fall asleep easily but wake many times during the night. Other people awaken too early in the morning and are then unable to get back to sleep. Some people even get enough hours of sleep but find that they do not feel rested, often because their sleep is too light.

Not all people experiencing insomnia have symptoms that occur during the daytime, but many do. Some people experience such symptoms as reduced ability to concentrate or pay attention, decreased alertness, and mental sluggishness. Some people have trouble staying awake. More people think that they have this symptom than actually do. Upon clinical examination many people who think that they are excessively sleepy during the day actually are not.

Many different things are thought to cause or contribute to insomnia. Such stressors as starting a new job or changes in routine, such as beginning to work a different shift, can lead to temporary sleep problems. Sleep problems can become aggravated, and persist after the worry or change causing the sleep problem has been resolved. This persistence is thought to be related to the anxiety created by attempting to go to sleep and not expecting to fall asleep. Anxiety about sleep loss can lead to a vicious circle in which the person has more and more concern about being able to fall asleep, making it ever increasingly difficult to do so. Some people even report that they are better able to fall asleep when they are not in their beds. This relative success is thought to occur because the new environment is not associated with the fear and anxiety of not being able to sleep, therefore making it easier to fall asleep.

Many other factors are thought to lead to or perpetuate insomnia. These include drinking tea or coffee, eating a large meal, taking certain medications or drugs of abuse (cocaine, amphetamines ) that have a stimulating effect, or exercising heavily in the hours before attempting to sleep. Also, attempting to sleep in a room with too much light or noise can make it harder for some people to sleep. Doing activities in bed that are not associated with sleep, such as reading or watching television, can make it more difficult for some people to fall asleep when they finally want to. Sleep may be even more difficult if the television show or book was frightening or upsetting.

Demographics

There are many different opinions about how much of the general American population experiences insomnia. Estimates suggest that around 5–20% of the adult population suffers from some form of insomnia or long-term sleeping problems. Nearly half report at least occasional sleeping problems. Accurate data is difficult to gather, as many people misperceive how much sleep they actually get and how many times they normally wake up during the night. It is generally agreed, however, that women are more likely than men to suffer from insomnia. As people get older, they are also are more likely to experience insomnia. People who are nervous or tense are more likely to have insomnia than those who are not. Lastly, people who live near airports or other sources of nighttime as well as daytime noise have higher rates of insomnia than the general population.

Diagnosis

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR ), which presents the guidelines used by the American Psychiatric Association for diagnosis of disorders, in order to be diagnosed with primary insomnia, a person must experience the symptoms for at least a month, and the symptoms must cause them distress or reduce their ability to function successfully. The symptoms cannot be caused by a different sleep disorder, a medical condition, or be a side effect of medications or substance abuse.

Insomnia may also be comorbid with (occur together with) other psychiatric disorders, including mania, depression, and the anxiety disorders.

Insomnia is a disorder that is usually self-reported; that is, patients usually bring up the subject of sleep problems with their doctors rather than the doctor suggesting the diagnosis. There are no laboratory tests for insomnia, but the doctor may suggest keeping a sleep diary, in which the patient notes the time they went to bed, the time(s) at which they got up during the night, their activities before bed, etc. Sleep diaries can be helpful in uncovering specific factors related to the insomnia.

Treatments

Many treatments have been explored for treating insomnia, in a number of different settings. The patient may wish to consider consulting a sleep clinic or a doctor who specializes in the treatment of sleep disorders as well as their family doctor.

Behavioral and educational therapies are usually tried first, because they do not have side effects and cannot create a chemical dependence the way some sleep medications can. Many different approaches have been designed to help patients whose insomnia is linked to particular factors.

Behavioral treatments

One common behavioral therapy involves changing any pre-bedtime activities or behaviors that might interfere with sleep. Avoiding large meals, alcohol or caffeinated beverages, or intensive exercise in the hours before bedtime may help the patient to fall asleep.

Another non-medicinal treatment for insomnia involves controlling the patient's mental associations with the bedroom. The patient is trained to associate the bed only with sleep, not with the frustration of trying to fall asleep or with such waking activities as reading or watching television. As part of this training, if the patient cannot sleep after a certain amount of time, he or she is instructed to get out of bed and spend time somewhere else in the house doing an activity that they find relaxing. The patient lies down again only when sleepy. This technique helps to prevent frustration from trying to sleep.

Another common technique that does not involve medication is sleep restriction therapy. During this therapy, the amount of time that patients are allowed to spend in bed is limited to only slightly more time than they believe that they already sleep at night. Gradually the amount of time patients are allowed to spend in bed is increased until they are getting a full night's sleep. Unfortunately, many people find this treatment difficult to stick with, because they often become mildly sleep-deprived. The resultant fatigue can be useful, however, as it may help them fall asleep more easily and to stay asleep longer at night.

Teaching relaxation and the ability to concentrate on relaxing thoughts or images can also help patients experiencing insomnia. Most of these therapies also include setting times for waking and having the patient stick to them even if he or she has not gotten a full night of sleep. The elimination of all daytime napping can help to facilitate sleep at night. These treatments are effective by themselves but may also be combined with other approaches. The course of treatment depends on the patient's specific symptoms.

Treatment with medications

Many different medicines, which are called hypnotics, are used to treat insomnia. These are usually not recommended for use for longer than a week because they may cause dependence. In addition, there is always the risk of side effects. There are many different types of hypnotics, and choosing one for a patient depends on the patient's symptoms, other drugs that he or she may be taking, any medical or psychological conditions, and other health factors. Medication treatment is best used in coordination with a behavioral therapy program.

Alternative remedies

Alternative remedies for insomnia, particularly herbal preparations, should be mentioned because they are among the most popular nonprescription treatments for sleep problems. According to Prevention magazine, insomnia is the sixth most common condition treated with herbal formulas in the United States; it accounts for 18% of all use of herbal preparations. Some herbs used for insomnia are safer than others. Persons who are using alternative remedies, whether to treat insomnia or other conditions, should always tell their doctor what they are taking, how much, and how often. This warning is important because some herbal preparations that are safe in themselves can interact with prescription medications.

Prognosis

Untreated insomnia has potentially serious consequences, including an increased risk of motor vehicle accidents, impaired school or job performance, and a high rate of absenteeism from work. Fortunately, insomnia can be treated very effectively in most patients. Treatment using a combination of approaches is usually most effective. Patients who have had insomnia once are at an increased risk for recurrent insomnia.

See also Caffeine and related disorders; Chamomile; Passionflower; Valerian

Resources

BOOKS

Aldrich, Michael S. Sleep Medicine. New York: Oxford University Press, 1999.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Insomnia." New York: Simon and Schuster, 2002.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry, 7th edition, Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Long, Scott F. "Preventing and Treating Insomnia" Drug Topics 144, no. 13 (July 3, 2000): 49.

Phillips, Grant T., Jeremy Holdsworth, Scott Cook. "How useful is cognitive behavioral therapy (CBT) for the treatment of chronic insomnia?" Journal of Family Practice 50, no. 7 (July 2001): 569.

ORGANIZATIONS

American Academy of Sleep Medicine. 6301 Bandel Road NW, Suite 101, Rochester, MN 55901. (507) 287-6006. <www.asda.org>.

Tish Davidson, A.M.