What is Insomnia?
Insomnia is defined as difficulty initiating or maintaining sleep, or both, despite adequate opportunity and time to sleep, leading to impaired daytime functioning. Insomnia may be due to poor quality or quantity of sleep.Insomnia is very common and occurs in 30% to 50% of the general population. Approximately 10% of the population may suffer from chronic ( i.e long-standing) insomnia.
Insomnia affects people of all ages including children, although it is more common in adults and its frequency increases with age. In general, women are affected more frequently than men.
Insomnia may be divided into three classes based on the duration of symptoms.
- Insomnia lasting one week or less may be termed Transient Insomnia;
- Short-term Insomnia lasts more than one week but resolves in less than three weeks; and
- Long-term Insomnia lasts more than three weeks.
It is important to make a distinction between insomnia and other similar terminology; short duration sleep and sleep deprivation.
- Short duration sleep may be normal in some individuals who may require less time for sleep without feeling daytime impairment, the central symptom in the definition of insomnia.
- In insomnia, adequate time and opportunity for sleep is available, whereas in sleep deprivation, lack of sleep is due to lack of opportunity or time to sleep because of voluntary or intentional avoidance of sleep.
Acute or short-term Insomnia is when symptoms last for several weeks.
Chronic Insomnia is characterized by insomnia that lasts for months and years.
Insomnia can affect all age groups and is more common in adult women than adult men. The condition can lead to poor performance at work or school, obesity, depression, anxiety, poor immune system function, reduced reaction time, and an increased risk and severity of long-term disease.
Causes of insomnia
Insomnia can be caused by physical factors as well as psychological factors. There is often an underlying medical condition that causes chronic insomnia, while transient insomnia may be due to a recent event or occurrence. Causes of insomnia include:- Drugs, alcohol, and medicines: caffeine, nicotine, alcohol, stimulants, antidepressants, heart and blood pressure medications, allergy medicines, decongestants, weight-loss medicines, antihistamines, cocaine, ephedrine, amphetamines, methamphetamine, fluoroquinolone antibiotic drugs
- Disruptions in circadian rhythm: jet lag, job shift changes, high altitudes, noisiness, hotness or coldness
- Psychological issues: stress, anxiety, depression, mania, schizophrenia
- Medical conditions: brain lesions and tumors, stroke, chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease (GERD), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson's and Alzheimer's diseases, hyperthyroidism, arthritis
- Hormones: estrogen, hormone shifts during menstruation
- Other factors: sleeping next to a snoring partner, parasites, genetic conditions, overactive mind, preganancy
Who Suffers Insomnia?
Some people are more likely to suffer from insomnia than others. These include:- Travelers
- Shift workers with frequent changes in shifts
- The elderly
- Drug users
- Adolescent or young adult students
- Pregnant women
- Menopausal women
- Those with mental health disorders
Symptoms of insomnia
Besides the conditions listed previously, there are other types of insomnia that are not necessarily linked to an underlying condition. Some of the common types of insomnia are listed in this section.
Psychophysiological insomniaPsychophysiological insomnia or primary insomnia is a type of insomnia in which learned behaviors prevent sleep. Individuals with this condition are unable to relax their minds (racing thoughts) and have an increased mental function when they try to fall sleep. This may become a long-term issue, and going to bed becomes associated with an increased level of anxiety and mental arousal, leading to chronic insomnia. This condition may be present in about 15% of people who undergo formal sleep studies for evaluation of chronic insomnia.
Idiopathic insomnia
Idiopathic insomnia (without an obvious cause) (childhood onset insomnia or life-long insomnia) is a less common condition (1% of young adults or adolescents) that starts in childhood and may continue into adulthood. These individuals have difficulty initiating and maintaining sleep and have chronic daytime fatigue. Other more common conditions need to be evaluated and ruled out before this diagnosis is made. This condition may run in families.
Paradoxical insomnia
Paradoxical insomnia is also called subjective insomnia or sleep state misconception. In this condition, individuals may report and complain of insomnia;, however, they would have a normal pattern of sleep if they were to have a formal overnight sleep study done.
Risk factors for insomnia?
Insomnia itself may be a symptom of an underlying medical condition. However, there are several signs and symptoms that are associated with insomnia.
- Difficulty falling asleep at night
- Awakening during the night
- Awakening earlier than desired
- Still feeling tired after a night's sleep
- Daytime fatigue or sleepiness
- Irritability, depression or anxiety
- Poor concentration and focus
- Being uncoordinated, an increase in errors or accidents
- Tension headaches
- Difficulty socializing
- Gastrointestinal symptoms
- Worrying about sleeping
How is insomnia diagnosed?
Evaluation and diagnosis of insomnia may start with a thorough medical and psychiatric patient history taken by the physician. As mentioned above, many medical and psychiatric conditions can be responsible for insomnia.
A general physical examination to assess for any abnormal findings is also important, including assessment of mental status and neurological function; heart, lung and abdominal exam; ear, nose and throat exam; and measurement of the neck circumference and waist size. Assessment of routine medications and use of any illegal drugs, alcohol, tobacco, or caffeine is also an important part of the medical history. Any laboratory or blood work pertinent to these conditions can also be a part of the assessment.The patient's family members and bed partners also need to be interviewed to ask about the patient's sleep patterns, snoring, or movements during sleep.
Specific questions regarding sleep habits and patterns are also a vital part of the assessment. A sleep history focuses on:
- duration of sleep,
- time of sleep,
- time to fall sleep,
- number and duration of awakenings,
- time of final awakening in the morning, and
- time and length of any daytime naps.
Sleep history also typically includes questions about possible symptoms associated with insomnia. The physician may ask about daytime functioning, fatigue, concentration and attention problems, naps, and other common symptoms of insomnia.
Other diagnostic tests may be done as part of the evaluation for insomnia, although they may not be necessary in all patients with insomnia.
Polysomnography is a test that is done in sleep centers if conditions such as sleep apnea are suspected. In this test, the person will be required to spend a full night at the sleep center while being monitored for heart rate, brain waves, respirations, movements, oxygen levels, and other parameters while they are sleeping. The data is then analyzed by a specially trained physician to diagnose or rule out sleep apnea.
Actigraphy is another more objective test that may be performed in certain situations but is not routinely a part of the evaluation for insomnia. An actigraph is a motion detector that senses the person's movements during sleep and wakefulness. It is worn similar to a wrist watch for days to weeks, and the movement data are recorded and analyzed to determine sleep patterns and movements.
This test may be useful in cases of primary insomnia disorder, circadian rhythm disorder, or sleep state misconception A sleep specialist usually will begin a diagnostic session by asking a battery of questions about your medical history and sleep patterns. A physical exam my be conducted to look for conditions that may be causing insomnia. Similarly, physicians may screen for psychiatric disorders and drug and alcohol use. It is not uncommon for a sleep specialist to request that you keep a sleeping diary.
More sophisticated tests may be employed such as a polysomnograph, which is an overnight sleeping test that records sleep patterns. In addition, actigraphy may be conducted, which uses a small, wrist-worn device called an actigraph to measure movement and sleep-wake patterns.
Insomnia Treatment
The treatment of insomnia depends largely on the cause of the problem. In cases where an obvious situational factor is responsible for the insomnia, correcting or removing the cause generally cures the insomnia. For example, if insomnia is related to a transient stressful situation, such as jet lag or an upcoming examination, then insomnia will be cured when the situation resolves.Generally speaking, the treatment of insomnia can be divided into non-medical or behavioral approaches and medical therapy. Both approaches are necessary to successfully treat insomnia, and combinations of these approaches may be more effective than either approach alone.
When insomnia is related to a known medical or psychiatric condition, then appropriate treatment of that condition is in the forefront of therapy for insomnia in addition to the specific therapy for insomnia itself. Without adequately addressing the underlying cause, insomnia will likely go on despite taking aggressive measures to treat it with both medical and non-medical therapies.
What are non-medical treatments for insomnia?
Some of the most important of these behavioral techniques are sleep hygiene, stimulus control, relaxation techniques, and sleep restriction.
Sleep hygiene
- Sleep as much as possible to feel rested, then get out of bed (do not over-sleep).
- Maintain a regular sleep schedule.
- Do not force yourself to sleep.
- Do not drink caffeinated beverages in the afternoon or evening.
- Do not drink alcohol prior to going to bed.
- Do not smoke, especially in the evening.
- Adjust the bedroom environment to induce sleep.
- Do not go to bed hungry.
- Resolve stress and anxiety before going to bed.
- Exercise regularly, but not 4-5 hours prior to bed time.
Some types of insomnia resolve themselves when the underlying cause is removed or wears off. In general, treating insomnia focuses on determining the cause of the sleeping problems. Once identified, this underlying cause can be properly treated or corrected. In addition to treating the underlying cause of insomnia, both medical and non-pharmacological (behavioral) treatments may be employed as adjuvant therapies.
Non-pharmacological apparaches to treating insomnia include:
- Improving "sleep hygiene" - don't over- or under-sleep, exercise daily, don't force sleep, try to maintain a regular sleep schedule, avoid caffeine at night, do not smoke, do not go to bed hungry, make sure the environment is comfortable
- Using relaxation techniques - such as meditation and muscle relaxation
- Cognitive therapy - one-on-one counseling or group therapy
- Stimulus control therapy - only go to bed when sleepy, refrain from TV, reading, eating, or worrying in bed, set an alarm for the same time every morning (even weekends), avoid long daytime naps
- Sleep restriction - decrease the time spent in bed and partially deprive your body of sleep so you are more tired the next night.
- Prescription sleeping pills (often benzodiazepines)
- Antidepressants
- Over-the-counter sleep aids
- Antihistamines
- Melatonin
- Ramelteon
- Valerian officinalis
Medications used to treat insomnia?
Several medications in the benzodiazepine class have been used successfully for the treatment of insomnia, and the most common ones include:
- quazepam (Doral),
- triazolam (Halcion),
- estazolam (ProSom),
- temazepam (Restoril),
- flurazepam (Dalmane), and
- lorazepam (Ativan).
Non-benzodiazepine sedatives are also used commonly for the treatment of insomnia and include most of the newer drugs. Some of the most common ones are:
- zaleplon (Sonata),
- zolpidem (Ambien or Ambien CR, Zolpimist, Intermezzo), and
- eszopiclone (Lunesta).
Ramelteon (Rozerem), which is an insomnia drug that acts by mimicking the action of melatonin, is a newer drug. It has been used effectively in certain group of patients with insomnia.
There are also other medications that are not in the sedative or hypnotic classes, which have been used in the treatment of insomnia. Sedative antihistamines, diphenhydramine (Benadryl) have been used as sleep aids because of their sedative effects; however, this is not a recommended use of these or other similar drugs due to many side effects and long-term drowsiness the following day.
Some anti-depressants [for example, trazodone (Desyrel), amitriptyline (Elavil, Endep), doxepin (Sinequan, Adapin)] can be used effectively to treat insomnia in patients who also may suffer from depression. Some anti-psychotics have been used to treat insomnia, although their routine use for this purpose is generally not recommended.
A doctor or sleep specialist is the best person to discuss these different medications, and to decide which one may be the best for each specific individual. Many of these drugs have a potential for abuse and addiction and need to be used with caution. None of these medications may be taken without the supervision of the prescribing physician.
High-resolution relational resonance-based electroencephalic mirroring, or HIRREM, also known as Brainwave Optimization, is a non-invasive method that sends the brain's frequencies back to itself with the use of musical tones. The result can be equilibrium between the two hemispheres of the brain, which appears to relieve the symptoms of insomnia. Put simply, mathematically organized musical tones may help treat insomnia.
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