Insomnia Overview

Most adults have experienced insomnia or sleeplessness at one time or another in their lives.
An estimated 30%-50% of the general population are affected by insomnia, and 10% have
chronic insomnia.

Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is

"difficulty initiating or maintaining sleep, or both" or the perception of poor quality sleep.
Insomnia may therefore be due to inadequate quality or quantity of sleep. Insomnia is not
defined by a specific number of hours of sleep that one gets, since individuals vary widely in
their sleep needs and practices. Although most of us know what insomnia is and how we feel
and perform after one or more sleepless nights, few seek medical advice. Many people
remain unaware of the behavioral and medical options available to treat insomnia.

Insomnia is generally classified based on the duration of the problem. Not everyone agrees on
one definition, but generally:

 symptoms lasting less than one week are classified as transient insomnia,

 symptoms between one to three weeks are classified as short-term insomnia, and

 those longer than three weeks are classified as chronic insomnia.

Statistics on Insomnia

Insomnia affects all age groups. Among adults, insomnia affects women more often than
men. The incidence tends to increase with age. It is typically more common in people in
lower socioeconomic (income) groups, chronic alcoholics, and mental health patients. Stress
most commonly triggers short-term or acute insomnia. If you do not address your insomnia,
however, it may develop into chronic insomnia.

Some surveys have shown that 30% to 35% of Americans reported difficulty falling asleep
during the previous year and about 10% reported problems with long standing insomnia.
There also seems to be an association between depression, anxiety, and insomnia. Although
the nature of this association is unknown, people with depression or anxiety were
significantly more likely to develop insomnia.

Insomnia Causes

Insomnia may be caused by a host of different reasons. These causes may be divided into
situational factors, medical or psychiatric conditions, or primary sleep problems. Insomnia
could also be classified by the duration of the symptoms into transient, short-term, or chronic.
Transient insomnia generally last less than seven days; short-term insomnia usually lasts for
about one to three weeks, and chronic insomnia lasts for more than three weeks.

Many of the causes of transient and short-term insomnia are similar and they include:

 Jet lag

 Changes in shift work

  Excessive or unpleasant noise

 Uncomfortable room temperature (too hot or too cold)

 Stressful situations in life (exam preparation, loss of a loved one, unemployment,

divorce, or separation)

 Presence of an acute medical or surgical illness or hospitalization

 Withdrawal from drug, alcohol, sedative, or stimulant medications

 Insomnia related to high altitude (mountains)

Uncontrolled physical symptoms (pain, fever, breathing problems, nasal congestion, cough,
diarrhea, etc.) can also cause someone to have insomnia. Controlling these symptoms and
their underlying causes may lead to resolution of insomnia.

Causes of Chronic or Long-Term Insomnia

The majority of causes of chronic or long-term insomnia are usually linked to an underlying
psychiatric or physiologic (medical) condition.

Psychological Causes of Insomnia

The most common psychological problems that may lead to insomnia include:

 anxiety,

 depression

 stress (mental, emotional, situational, etc),

 schizophrenia, and/or

 mania (bipolar disorder)

Insomnia may be an indicator of depression. Many people will have insomnia during the
acute phases of a mental illness. As mentioned earlier, depression and anxiety are strongly
associated with insomnia. Out of the all the other secondary medical and psychological
causes of insomnia, anxiety and depression are the most common.

Physiological Causes of Insomnia

Physiological causes span from circadian rhythm disorders (disturbance of the biological
clock), sleep-wake imbalance, to a variety of medical conditions. The following are the most
common medical conditions that trigger insomnia:

 Chronic pain syndromes

 Chronic fatigue syndrome

  Congestive heart failure

 Night time angina (chest pain) from heart disease

 Acid reflux disease (GERD)

 Chronic obstructive pulmonary disease (COPD)

 Nocturnal asthma (asthma with night time breathing symptoms)

 Obstructive sleep apnea

 Degenerative diseases, such as Parkinson's disease and Alzheimer's disease (Often

insomnia is the deciding factor for nursing home placement.)

 Brain tumors, strokes, or trauma to the brain

High Risk Groups for Insomnia

In addition to people with the above medical conditions, certain groups may be at higher risk
for developing insomnia:

 Travelers

 Shift workers with frequent changing of shifts

 Seniors

 Adolescents or young adult students

 Pregnant women

 Women in menopause

 People who use abuse drugs

 Alcoholics

Medication Related Insomnia

Certain medications have also been associated with insomnia. Among them are:

 Certain over-the-counter cold and asthma preparations.

 The prescription varieties of these medications may also contain stimulants and thus
produce similar effects on sleep.

 Some medications used to treat high blood pressure have also been associated with
poor sleep.

 Some medications used to treat depression, anxiety, and schizophrenia.

Other Causes of Insomnia

 Common stimulants associated with poor sleep include caffeine and nicotine. You
should consider not only restricting caffeine and nicotine use in the hours immediately
before bedtime but also limiting your total daily intake.

 People often use alcohol to help induce sleep, as a nightcap. However, it is a poor
choice. Alcohol is associated with sleep disruption and creates a sense of non-
refreshed sleep in the morning.

 A disruptive bed partner with loud snoring or periodic leg movements also may
impair your ability to get a good night's sleep.

Insomnia Symptoms

Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms
intertwine with those of other medical or mental conditions.

 Some people with insomnia may complain of difficulty falling asleep or waking up
frequently during the night. The problem may begin with stress. Then, as you begin to
associate the bed with your inability to sleep, the problem may become chronic.

 Most often daytime symptoms will bring people to seek medical attention. Daytime
problems caused by insomnia include the following:

o Poor concentration and focus

o Difficulty with memory

o Impaired motor coordination (being uncoordinated)

o Irritability and impaired social interaction

o Motor vehicle accidents because of fatigued, sleep-deprived drivers

 People may worsen these daytime symptoms by their own attempts to treat the
symptoms.

o Alcohol and antihistamines may compound the problems with sleep

deprivation.

o Others have tried nonprescription sleep aids.

Many people with insomnia do not complain of daytime sleepiness, and in fact, they may
have difficulty falling asleep during intentional daytime naps.

Primary Sleep Disorders

In addition to the causes and conditions listed above, there are also a number of conditions
that are associated with insomnia in the absence of another underlying condition. These are
called primary sleep disorders, in which the sleep disorder is the main cause of insomnia.
These conditions generally cause chronic or long-term insomnia. Some of the diseases are
listed below:

 Idiopathic insomnia (unknown cause) or childhood insomnia, which start early on in

life and results in lifelong sleep problems. This may run in families.

 Central sleep apnea. This is a complex disorder. It can be the primary cause of the
insomnia itself or it may be caused by other conditions, such as brain injury, heart
failure, high altitude, and low oxygen levels.

 Restless legs syndrome (a condition associated with creeping sensations in the leg
during sleep that are relieved by leg movement)

 Periodic Limb movement disorder (a condition associated with involuntary

repeated leg movement during sleep)

 Circadian rhythm disorders (disturbance of the biological clock) which are

conditions with unusual timing of sleep (for example, going to sleep later and waking
up late, or going to sleep very early and getting up very early).

 Sleep state misperception, in which the patient has a perception or feeling of not
sleeping adequately, but there are no objective (polysomnographic or actigraphic)
findings of any sleep disturbance.

 Insufficient sleep syndrome, in which the person's sleep is insufficient because of

environmental situations and lifestyle choices, such as sleeping in a bright or noisy
room.

 Inadequate sleep hygiene, in which the individual has poor sleep or sleep
preparation habits (described in the following treatment section.)

When to Seek Medical Care

When to call the doctor

 A person with insomnia needs a doctor's attention if it lasts longer than three to four
weeks, or sooner if it interferes with a person's daytime activities and ability to
function.

 Insomnia is generally a symptom of an underlying situation or another medical or

psychological problem, which may need to be addressed first or at the same time.

When to go to the hospital

 Generally, a person will not be hospitalized for most types of insomnia. However,
accidents may result from poor coordination and attention lapse seen with sleep
deprivation.
  Worsening pain or increased difficulty breathing at night also may indicate a person
needs to seek emergency medical care.

Insomnia Diagnosis

The health care practitioner will begin an evaluation of insomnia with a complete medical
history. As with most medical evaluations, a complete medical history and physical
examination are important aspects of assessment and treatment of insomnia.

The health care practitioner will seek to identify any medical or psychological illness that
may be contributing to the patient's insomnia. A thorough medical history and examination
including screening for psychiatric disorders and drug and alcohol use is paramount in
evaluation of a patient with sleep problems. Physical examination may particularly focus on
heart and lung examination, and measurement of size of the neck and visualizing oral and
nasal air passages (to see whether sleep apnea needs to be assessed in more detail).

 A patient with insomnia may be asked about chronic snoring and recent weight gain.
This may direct an investigation into the possibility of obstructive sleep apnea. In
such an instance, the doctor may request an overnight sleep test (polysomnogram).
Sleep studies are frequently done in specialized "sleep labs" by doctors trained in
sleep medicine, frequently working with pulmonary (lung) specialists. This test is not
part of the routine initial workup for insomnia, however.

 Sleep history can be helpful in evaluating a patient with insomnia. Sleep schedule,
bedroom and sleep habits, timing and quality of sleep, daytime symptoms, and
duration of insomnia can provide useful clues in the assessment of a patient with
insomnia.

 Routine medications, alcohol use, drug use, stressful social and occupational
situations, sleeping habits or snoring of the bed partner, and work schedule are some
of the other topics that may be discussed by your doctor when evaluating insomnia.

 The Epworth Sleepiness Scale is a validated questionnaire that can be used to assess
daytime sleepiness. This scale may be helpful in assessing insomnia.

 Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs

are small, wrist-worn devices (about the size of a wristwatch) that measure
movement. They contain a microprocessor and on-board memory and can provide
objective data on daytime activity.

 A sleep diary can be filled out daily for a period of 2 weeks. The patient is asked to
write down times when they go to bed, fall asleep, awake from sleep, stay awake in
bed, and get up in the morning. They can record amount of daily exercise, alcohol and
caffeine intake, and medication. The diary will include the patient's personal
assessment of their alertness at various times of the day on two consecutive days
within the 2 week period.

Insomnia Treatment
In general, transient insomnia resolves when the underlying trigger is removed or corrected.
Most people seek medical attention when their insomnia becomes chronic.

The main focus of treatment for insomnia should be directed towards finding the cause. Once
a cause is identified, it is important to manage and control the underlying problem, as this
alone may eliminate the insomnia all together. Treating the symptoms of insomnia without
addressing the main cause is rarely successful. In the majority of cases, chronic insomnia can
be cured if its medical or psychiatric causes are evaluated and treated properly.

The following therapies may be used in conjunction with therapies directed towards the
underlying medical or psychiatric cause. They are also the recommended therapies for some
of the primary insomnia disorders.

Generally, treatment of insomnia entails both non-pharmacologic (non-medical) and

pharmacologic (medical) aspects. It is best to tailor treatment for individual patient based on
the potential cause. Studies have shown that combining medical and non-medical treatments
typically is more successful in treating insomnia than either one alone.

Insomnia Non-Medical treatment and Behavioral Therapy

Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus

control, and sleep restriction. These also are referred to as cognitive behavioral therapies.

Sleep Hygiene

Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple
steps can be taken to improve a patient's sleep quality and quantity. These steps include:

 Sleep as much as you need to feel rested; do not oversleep.

 Exercise regularly at least 20 minutes daily, ideally 4-5 hours before your bedtime.

 Avoid forcing yourself to sleep.

 Keep a regular sleep and awakening schedule.

 Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks
etc.) Avoid "night caps," (alcoholic drinks prior to going to bed).

 Do not smoke, especially in the evening.

 Do not go to bed hungry.

 Adjust the environment in the room (lights, temperature, noise, etc.)

 Do not go to bed with your worries; try to resolve them before going to bed.

Relaxation Therapy
Relaxation therapy involves measures such as meditation and muscle relaxation or dimming
the lights and playing soothing music prior to going to bed.

Stimulus Control

Stimulus control therapy also consists of a few simple steps that may help patients with
chronic insomnia.

 Go to bed when you feel sleepy.

 Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep
and sexual activity.

 If you do not fall asleep 30 minutes after going to bed, get up and go to another room
and resume your relaxation techniques.

 Set your alarm clock to get up at a certain time each morning, even on weekends. Do
not oversleep.

 Avoid taking long naps in the daytime.

Sleep Restriction

Restricting your time in bed only to sleep may improve your quality of sleep. This therapy is
called sleep restriction. It is achieved by averaging the time in bed that the patient spends
only sleeping. Rigid bedtime and rise time are set, and the patient is forced to get up at the
rising time even if they feel sleepy. This may help the patient sleep better the next night
because of the sleep deprivation from the previous night. Sleep restriction has been helpful in
some cases.

Other simple measures that can be helpful to treat insomnia include:

 Avoid large meals and excessive fluids before bedtime

 Control your environment.

o Light, noise, and undesirable room temperature can disrupt sleep. Shift
workers and night workers especially must address these factors. Dimming the
lights in the bedroom, relaxation, limiting the noise, and avoiding stressful
tasks before going to bed may be beneficial. (Refer to sleep hygiene and
relaxation therapy above.)

o Avoid doing work in the bedroom that should be done somewhere else. For
example, do not work or operate your business out of your bedroom and avoid
watching TV, reading books, and eating in your bed.

A person's circadian rhythm (biological clock) is particularly sensitive to light. Parents who
need to sleep during the day may have to make child care arrangements to allow them to
sleep.
Insomnia Medications and Medical Therapies

There are numerous prescription medications to treat insomnia. Generally, it is advised that
they should not be used as the only therapy and that treatment is more successful if combined
with non-medical therapies. In a study, it was noted that when sedatives were combined with
behavioral therapy, more patients were likely to wean off the sedatives than if sedatives were
used alone. The most commonly used sleeping pills are listed in the following sections
including over-the-counter medications and natural sleep aids.

Prescription Sleep Aids

 Benzodiazepine sedatives: Six of these sedative drugs have been used to treat
insomnia. There are reports of subjective improvement of quality and quantity of
sleep when using these medications. Examples include, temazepam (Restoril),
flurazepam (Dalmane), triazolam (Halcion), estazolam (ProSom, Eurodin), lorazepam
(Ativan), and clonazepam (Klonopin).

 Nonbenzodiazepine sedatives: Examples include, eszopiclone (Lunesta), zaleplon

(Sonata), and zolpidem (Ambien).

 Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors.

Ramelteon promotes the onset of sleep and helps normalize circadian rhythm
disorders. Ramelteon is approved by the US Food and Drug Administration (FDA) for
treatment of insomnia characterized by difficulty falling asleep.

 Some antidepressants (for example, amitriptyline [Elavil, Endep] and trazodone

[Desyrel]) have been used for the treatment of insomnia in patients with co-existing
depression because of some sedative properties. Generally, they may not be helpful
for insomnia in people without depression.

Over-the-Counter (OTC) Medications

 Antihistamines with sedative properties [for example, diphenhydramine (Benadryl)

or doxylamine] have also been used in treating insomnia as they may induce
drowsiness, but they do not improve sleep and should not be used to treat chronic
insomnia.

 Melatonin: Melatonin is secreted by the pineal gland, a pea-sized structure at the

center of the brain. Melatonin is produced during the dark hours of the day-night
cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours.
The pineal gland responds to darkness by increasing melatonin levels in the body.
This process is thought to be integral to maintaining circadian rhythm. At night,
melatonin is produced to help your body regulate your sleep-wake cycles. The amount
of melatonin produced by your body seems to decrease as you get older. Melatonin
supplements may be beneficial in patients with circadian rhythm problems.

Herbal Remedies for Insomnia

  Valeriana officinalis (Valerian) is a popular herbal medication used in the United
States for treating insomnia with possibly some benefit in some patients with chronic
insomnia.

 St. Johns Wort and chamomile have not shown any real benefit in treating insomnia.

 Other natural herbal sleeping aids such as, dogwood, kava kava, and L-tryptophan,
may be associated with potential adverse effect when used for insomnia.

Follow-up

Follow the health care practitioner's recommendations for the patient's medical and
psychological conditions. The patient will be asked to give their doctor feedback after they
have followed a treatment plan.

Often the patient will have more than one option and more than one medication available to
help them. A patient should not lose hope if the first medication does not give them the
results they want or if they experience side effects or concerns. Report back to your doctor
for advice.

Insomnia Prevention

The following are suggestions to help anticipate and modify situations likely to be associated
with insomnia. They are not foolproof, nor will they safeguard the patient from the
consequences of sleep deprivation once it has occurred.

Insomnia from Jet Lag

 Behavioral and short-term drug therapy has been used.

 If the person traveling can anticipate a trip, begin to shift bedtime to coincide with the
time schedule at the destination.

 Short-acting tranquilizers (benzodiazepines) have been shown to be useful.

Melatonin, a hormone secreted by the pineal gland that regulates our sleep-wake
cycles, has also been used.

Insomnia from shift changes

 Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep
deprivation in shift workers.

 A person should shift their schedules forward in a clockwise direction, from days to
evening, then evenings to night shift, and allow sufficient time to adapt (at least one
week) between shift changes.

 Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as
a rhythm synchronizer.
  Shift workers should stress the importance of good sleep habits with regular bedtime
and awakening.

o Supplemental naps may be necessary to ensure work time alertness.

o Discuss the use of naps with a doctor.

o Some people promote using short-acting sedatives in the first few days
following a shift change, but not everyone agrees.

Insomnia from Acute Stresses

 Stress may be positive or negative, and concerns about sleep may vary. Many
stressors will go away with support and reassurance.

 Education about the importance of good sleep habits is also helpful.

 Some people may need short-term treatment with medications. A doctor will often
work toward the lowest effective dose with a short-acting sedative to achieve proper
sleep.

General recommendations for prevention of insomnia include the following:

 Work to improve your sleep habits.

o Learn to relax. Self-hypnosis, biofeedback and relaxation breathing are often

helpful.

o Control your environment. Avoid light, noise, and excessive temperatures.

Use the bed only to sleep and avoid using it for reading and watching TV.
Sexual activity is an exception.

o Establish a bedtime routine. Fix wake time.

 Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and
reduce the use of stimulants including caffeine and nicotine.

 If you do not fall asleep within 20 to 30 minutes, try a relaxing activity such as
listening to soothing music or reading.

 Limit daytime naps to less than 15 minutes unless directed by your doctor.

o It is generally preferable to avoid naps whenever possible to help consolidate

your night's sleep.

o There are certain sleep disorders, however, that will benefit from naps.
Discuss this issue with your doctor.
Insomnia Prognosis

Recovery from insomnia can vary.

 If you have insomnia caused by jet lag, your symptoms will generally clear up within
a few days.

 If you are depressed and have had insomnia for many months, it is unlikely that your
symptoms will go away on their own. You may need further evaluation and treatment.

 Your outcome will also depend on coexisting medical conditions, which may include
congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic
pain syndromes.