Insomnia 50798 226061351 2008-07-16T17:32:33Z CarsracBot 6929011 robot Adding: [[simple:Insomnia]] {{this|the sleeping disorder}} {{Expert-subject|Neuroscience|article|date=December 2007}} {{Infobox_Disease | Name = Insomnia | Image = | Caption = |SEX DiseasesDB = 26877 | ICD10 = {{ICD10|F|51|0|f|50}}, {{ICD10|G|47|0|g|40}} | ICD9 = {{ICD9|307.42}}, {{ICD9|307.41}}, {{ICD9|780.51}}, {{ICD9|780.52}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = med | eMedicineTopic = 2698 | MeshID = D007319 | }} '''Insomnia''' is a symptom of a [[sleep disorder|sleeping disorder]] characterized by persistent difficulty falling [[sleep|asleep]] or staying asleep despite the opportunity. It is typically followed by functional impairment while awake. Insomniacs have been known to complain about being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and non-organic insomnia constitute a [[sleep disorder]].<ref name="WHO1">{{cite web |url=http://www3.who.int/icd/currentversion/fr-icd.htm?gf50.htm+f510 |title=WHO |accessdate=2007-12-16 |format= |work=}}</ref><ref name="WHO2">{{cite web |url=http://www3.who.int/icd/currentversion/fr-icd.htm?gg40.htm+g47 |title=WHO |accessdate=2007-12-16 |format= |work=}}</ref> According to the U.S. [[Department of Health and Human Services]] in year 2007, approximately 64 million Americans suffer from insomnia each year.<ref name="titleBrain Basics: Understanding Sleep: National Institute of Neurological Disorders and Stroke (NINDS)">{{cite web |url=http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm |title=Brain Basics: Understanding Sleep: National Institute of Neurological Disorders and Stroke (NINDS) |accessdate=2007-12-16 |format= |work=}}</ref> Insomnia occurs 1.4 times more commonly in women than in men.<ref>{{cite web |url=http://pn.psychiatryonline.org/cgi/content/full/42/10/40 |title=Several Sleep Disorders Reflect Gender Differences |accessdate=2008-09-05}}</ref> ==Types of Insomnia== Although there are several different degrees of insomnia, about three types of insomnia have been clearly identified: transient, acute, and chronic. #'''Transient insomnia''' lasts from days to weeks. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, or by stress. Its consequences - sleepiness and impaired psychomotor performance - are similar to those of [[sleep deprivation]].<ref name="Roth">{{cite journal | last = Roth | first = Thomas | coauthors = Timothy Roehrs | title = Insomnia: Epidemiology, characteristics, and consequences | journal = Clinical Cornerstone | volume = 5 | issue = 3 | pages = 5–15 | date = 2004-02-25 | url = | doi = 10.1016/S1098-3597(03)90031-7 | accessdate = 2007-12-18 }}</ref> If this form of insomnia continues to occur from time to time, the insomnia is classified as intermittent.{{Fact|date=December 2007}} #'''[[Acute (medicine)|Acute]] insomnia''' is the inability to consistently sleep well for a period of between three weeks to six months.<ref>{{cite web |url=http://articles.directorym.com/Insomnia-a352.html|title=Insomnia - sleeplessness, chronic insomnia, acute insomnia, mental ...|publisher =driectoryM articles|accessdate=2008-04-29}}</ref> #'''[[chronic (medical)|Chronic]] insomnia''' lasts for years and years at a time. It can be caused by another disorder, or it can be a primary disorder. Its effects can vary according to its causes. They might include sleepiness, muscular fatigue, hallucinations, and/or mental fatigue; but people with chronic insomnia often show increased alertness. Some people that live with this disorder see things as though they were happening in slow motion, whereas moving objects seem to blend together.<ref name="Roth"/> == Patterns of Insomnia== The pattern of insomnia often is related to the etiology.<ref>http://www.emedicine.com/MED/topic609.htm</ref> # Onset insomnia - difficulty falling asleep at the beginning of the night, often associated with [[anxiety disorder]]s. # [[Middle-of-the-Night Insomnia]] - Insomnia characterized by difficulty returning to sleep after awakening in the middle of the night or waking too early in the morning. Also referred to as nocturnal awakenings. Encompasses middle and terminal insomnia. # Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with [[pain syndrome]]s or medical illness. # Terminal (or late) insomnia - early morning waking. Characteristic of [[clinical depression]]. ==Causes== Insomnia can be caused by: *[[Psychoactive drug]]s or [[stimulant]]s, including certain [[medications]], [[herbs]], [[caffeine]], [[cocaine]], [[ephedrine]], [[amphetamine]]s, [[methylphenidate]], [[MDMA]], [[methamphetamine]] and [[modafinil]] *[[Hormone]] shifts such as those that precede [[menstruation]] and those during [[menopause]] *Life problems like [[fear]], [[stress (psychology)|stress]], [[anxiety]], emotional or mental tension, work problems, financial stress, unsatisfactory sex life *[[Mental disorder]]s such as [[clinical depression]], [[schizophrenia]], [[bipolar disorder]], [[general anxiety disorder]] *[[Circadian rhythm sleep disorder|Disturbances of the circadian rhythm]], such as [[shift work]] and [[jet lag]], can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Jet lag is seen in people who travel through multiple time zones, as the time relative to the rising and setting of the sun no longer coincides with the body's internal concept of it. The insomnia experienced by shift workers is also a circadian rhythm sleep disorder. * Certain [[Neurology|neurological disorders]], [[brain]] [[lesion]]s, or a [[Medical history|history]] of [[traumatic brain injury]] *[[Disease|Medical conditions]] such as [[hyperthyroidism]] and [[Wilson's syndrome]] *Abuse of over-the counter or prescription sleep aids can produce [[rebound insomnia]] *Poor [[sleep hygiene]] *[[Parasomnia]], which includes a number of disruptive sleep events including nightmares, sleepwalking, violent behavior while sleeping, and [[rapid eye movement behavior disorder|REM behavior disorder]], in which a person moves his/her physical body in response to events within his/her dreams *The [[full moon]] lunar phase<ref>[http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2869.2006.00520.x Sleepless night, the moon is bright: longitudinal study of lunar phase and sleep]</ref> *A rare genetic condition can cause a [[prion]]-based, permanent and eventually fatal form of insomnia called [[fatal familial insomnia]] A common misperception is that the amount of sleep a person requires decreases as he or she ages. The ability to sleep for long periods, rather than the need for sleep, appears to be lost as people get older. Some elderly insomniacs toss and turn in bed and occasionally fall off the bed at night, diminishing the amount of sleep they receive.<ref>[http://www.aafp.org/afp/991001ap/1431.html American Family Physician: Chronic Insomnia: A Practical Review]</ref> An overactive mind or physical pain may also be causes. Finding the underlying cause of insomnia is usually necessary to cure it. Insomnia can be common after the loss of a loved one, even years or decades after the death, if they have not gone through the grieving process. Overall, however, symptoms and the degree of severity affects different people differently, depending on their mental health, physical condition, and attitude or personality. ==Diagnosis== Patients with [[delayed sleep phase syndrome]] are often mis-diagnosed with insomnia. If the patient has trouble getting to sleep, but has normal sleep architecture once asleep, a [[circadian rhythm]] disorder is a more likely cause. ==Insomnia Versus Poor Sleep Quality== Poor sleep quality can occur as a result of sleep apnea or [[clinical depression]]. Poor sleep quality is caused by the individual not reaching stage 4 or delta sleep which has restorative properties. There are, however, people who are unable to achieve stage 4 sleep due to brain damage who still lead perfectly normal lives. *[[Sleep apnea]] is a condition that occurs when a sleeping person's breathing is interrupted, thus interrupting the normal sleep cycle. With the obstructive form of the condition, some part of the sleeper's respiratory tract loses muscle tone and partially collapses. People with obstructive sleep apnea often do not remember awakening or having difficulty breathing, but they complain of excessive sleepiness during the day. Central sleep apnea interrupts the normal breathing stimulus of the [[central nervous system]], and the individual must actually wake up to resume breathing. This form of apnea is often related to a cerebral vascular condition, congestive heart failure, and premature aging. Major depression leads to alterations in the function of the [[hypothalamic-pituitary-adrenal axis]], causing excessive release of [[cortisol]] which can lead to poor sleep quality. Nocturnal [[polyuria]] or excessive nighttime urination can be very disturbing to sleep.<ref>{{cite book | coauthors = Adler and Thorpy | title = Sleep issues in Parkinson’s disease | url = http://www.neurology.org/cgi/content/full/64/12_suppl_3/S12 | accessyear = 2007 | accessmonth = June | year = 2005 | publisher = Neurology | language = English | pages = 64; S12-20 }}</ref> Nocturnal polyuria can be nephrogenic (related to kidney disease) or it may be due to prostate enlargement or hormonal influences.{{Fact|date=April 2007}} Deficiencies in vasopressin, which is either caused by a pituitary problem or by insensitivity of the kidney to the effects of vasopressin, can lead to nocturnal polyuria.{{Fact|date=April 2007}} Excessive thirst or the use of diuretics can also cause these symptoms.{{Fact|date=April 2007}} ==Treatment for Insomnia== In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful. ===Medications=== Many insomniacs rely on [[sleeping tablet]]s and other [[sedative]]s to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as [[benzodiazepine]]s and newer [[nonbenzodiazepine]] drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully [[Titration|titrated]] down. In comparing the options, a [[systematic review]] found that [[benzodiazepine]]s and [[nonbenzodiazepine]]s have similar efficacy which was [[statistical significance| insignificantly]] more than for [[antidepressant]]s.<ref name="pmid17619935">{{Cite journal | author = Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M. | title = The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs | journal = [[J Gen Intern Med]] | year = [[2007]] | month = September | volume = 22 | issue = 9 | pages = 1335&ndash;1350 | pmid = 17619935 | doi = 10.1007/s11606-007-0251-z }}</ref> Benzodiazepines had an [[statistical significance|insignificant]] tendency for more [[adverse drug reaction]]s.<ref name="pmid17619935"/> ====Benzodiazepines==== {{main|Benzodiazepine}} The most commonly used class of hypnotics prescribed for insomnia are the [[benzodiazepine]]s. [[Benzodiazepine]]s bind unselectively to the [[GABAA receptor|GABA<sub>A</sub> receptor]].<ref name="pmid17619935"/> This includes drugs such as [[temazepam]], [[flunitrazepam]], [[triazolam]], [[flurazepam]], [[nitrazepam]] and [[midazolam]]. These medications can develop tolerance and dependence, especially after consistent usage over long periods of time. ====Non-benzodiazepines==== {{main|Nonbenzodiazepine}} [[Nonbenzodiazepine]] prescription drugs, such as Ambien ([[zolpidem]]), Sonata ([[zopiclone]]) and Lunesta ([[eszopiclone]]), are more selective for the [[GABAA receptor|GABA<sub>A</sub> receptor]]<ref name="pmid17619935"/> and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both [[Addiction#Psychological addiction|psychological dependence]] and [[physical dependence]] though less than traditional benzodiazepines, and can also cause the same memory and cognitive disturbances along with morning sedation. They belong to the new category of medications called sedative-hypnotics. ====Antidepressants==== {{main|Antidepressants}} Some older [[antidepressant]]s such as [[amitriptyline]], [[doxepin]], [[mirtazapine]], and [[trazodone]] may have a sedative effect, and are prescribed [[off label]] to treat insomnia. The major drawback of these drugs is that they have [[antihistaminergic]], [[anticholinergic]] and [[antiadrenergic]] properties which can lead to many side effects. Some also alter [[sleep architecture]]. As with many benzodiazepines, the use of antidepressants in the treatment of insomnia can lead to [[physical dependence]]; withdrawal may induce [[rebound insomnia]] and actually further complicate matters in the long-term. ====Melatonin==== [[Melatonin]] has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon ([[Rozerem]]), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation. Natural substances such as [[5-HTP]] and L-[[Tryptophan]] have been said to fortify the [[serotonin]] -> melatonin pathway and aid people with various sleep disorders including insomnia.<ref>Morton Walker, DPM - [http://www.biochemicals.com/townsend/index.htm The Restoration of L-Tryptophan with Its Numerous Physiological Benefits]</ref> ====Antihistamines==== The [[antihistamine]] Benedryl ([[diphenhydramine]]) is widely used in nonprescription sleep aids such as Tylenol PM, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs. Periactic ([[Cyproheptadine]]) is a useful alternative to [[benzodiazepine]] hypnotics in the treatment of insomnia. Cyproheptadine may be superior to benzodiazepines in the treatment of insomnia because cyproheptadine enhances sleep quality and quantity whereas benzodiazepines tend to decrease sleep quality.<ref>{{cite journal | author = Tokunaga S | coauthors = Takeda Y, Shinomiya K, Hirase M, Kamei C. | year = 2007 | month = Feb | title = Effects of some H1-antagonists on the sleep-wake cycle in sleep-disturbed rats. | journal = J Pharmacol Sci. | volume = 103 | issue = 2 | pages = 201–6 | pmid = 17287588 | url = http://www.jstage.jst.go.jp/article/jphs/103/2/201/_pdf | format = pdf | doi = 10.1254/jphs.FP0061173 }}</ref> ====Atypical Antipsychotics==== Low doses of certain [[atypical antipsychotics]] such as [[quetiapine]] (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia. Over time, Seroquel may lose it's ability to produce sedation. ===Other Substances=== Some insomniacs use [[herb]]s such as [[valerian plant|valerian]], [[chamomile]], [[lavender]], [[hops]], and [[passion-flower]]. Valerian has undergone multiple studies and appears to be modestly effective.<ref name="pmid10761819">{{cite journal |author=Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I |title=Critical evaluation of the effect of valerian extract on sleep structure and sleep quality |journal=Pharmacopsychiatry |volume=33 |issue=2 |pages=47–53 |year=2000 |pmid=10761819| doi = 10.1055/s-2000-7972 <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid16335333">{{cite journal |author=Morin CM, Koetter U, Bastien C, Ware JC, Wooten V |title=Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial |journal=Sleep |volume=28 |issue=11 |pages=1465–71 |year=2005 |pmid=16335333 |doi=}}</ref><ref name="pmid17561634">{{cite journal |author=Meolie AL, Rosen C, Kristo D, ''et al'' |title=Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence |journal=Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine |volume=1 |issue=2 |pages=173–87 |year=2005 |pmid=17561634 |doi=}}</ref> [[Cannabis]] has also been suggested as a very effective treatment for insomnia. An old wive's tale once suggested that sucking on a lemon and gurgling water while trying to count backwards from 100 once was thought to cure insomnia.<ref>[http://www.cannabis.net/medical-marijuana/pot-docs.html http://www.cannabis.net/medical-marijuana/pot-docs.html ]</ref> Though [[alcohol]] may have sedative properties, the [[Rapid eye movement sleep|REM sleep]] suppressing effects of the drug prevent restful, quality sleep.{{Fact|date=February 2007}} Also, [[middle-of-the-night awakenings]] due to [[polyuria]] or other effects from alcohol consumption are common, and [[Hangover|hangovers]] can also lead to morning grogginess. Insomnia may be a symptom of [[magnesium deficiency (medicine)|magnesium deficiency]], or lower [[magnesium]] levels. A healthy diet containing [[magnesium]], can help to improve sleep in individuals without an adequate intake of [[magnesium]].<ref name="pmid9703590">{{cite journal |author=Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann D |title=Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study |journal=Sleep |volume=21 |issue=5 |pages=501–5 |year=1998 |pmid=9703590 |doi=}}</ref> Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal.<ref>{{cite web|url=http://www.cidervinegar.org/2007/06/cider-vinegar-rocks.html|title=Cider Vinegar and Insomnia}}</ref> ===Cognitive behavior therapy=== Recent research has shown that [[Cognitive therapy|cognitive behavior therapy]] can be more effective than medication in controlling insomnia.<ref name="JacobsG2004Cognitive">{{Cite journal | last = Jacobs | first = Gregg | authorlink = Gregg Jacobs | coauthors = Edward F. Pace-Schott, Robert Stickgold, Michael W. Otto | title = Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison | journal = [[Archives of Internal Medicine]] | volume = 164 | issue = 17 | pages = 1888–1896 |date=September 27, 2004 | doi = 10.1001/archinte.164.17.1888 | pmid = 15451764 }}</ref> In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep.<ref name="JacobsG2004Cognitive">{{cite journal | last = Jacobs | first = Gregg | authorlink = Gregg Jacobs | coauthors = Edward F. Pace-Schott, Robert Stickgold, Michael W. Otto | title = Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison | journal = [[Archives of Internal Medicine]] | volume = 164 | issue = 17 | pages = 1888–1896 | date = September 27, 2004 | doi = 10.1001/archinte.164.17.1888 | pmid = 15451764 }}</ref> ===Complementary and Alternative medicine=== Some traditional and anecdotal remedies for insomnia include: drinking warm milk before bedtime, taking a warm bath, exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, going to bed at a reasonable hour and getting up early, and avoiding exposing the eyes to too much light, especially blue light, a few hours before bedtime. Initial treatment of insomnia may include the rules of [[Sleep Hygiene]] Using [[aromatherapy]], including jasmine oil, [[lavender oil]], [[Mahabhringaraj]] and other relaxing [[essential oil]]s, may also help induce a state of restfulness. Many believe that listening to slow paced music will help insomniacs fall asleep. <ref name="pmid16269944">{{cite journal |author=Robinson SB, Weitzel T, Henderson L |title=The Sh-h-h-h Project: nonpharmacological interventions |journal=Holistic nursing practice |volume=19 |issue=6 |pages=263–6 |year=2005 |pmid=16269944 |doi=}}</ref> The more relaxed a person is, the greater the likelihood of getting a good night's sleep. [[Relaxation techniques]] such as [[meditation]] have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.{{Fact|date=February 2007}} [[Traditional Chinese medicine]] has included treatment for insomnia. A typical approach may utilize [[acupuncture]], dietary and lifestyle analysis, [[Herbalism|herbology]] and other techniques, with the goal of resolving the problem at a subtle level. In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or ''[[metta]]''. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body.<ref>{{cite journal |author=Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ |title=Long-term meditators self-induce high-amplitude gamma synchrony during mental practice |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=101 |issue=46 |pages=16369–73 |year=2004 |pmid=15534199 |doi=10.1073/pnas.0407401101 |url=http://www.pnas.org/cgi/content/full/101/46/16369 }}</ref> This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the ''Mettā (Mettanisamsa) Sutta'',<ref name="titleAN 11.16: Metta (Mettanisamsa) Sutta">{{cite web |url=http://www.accesstoinsight.org/tipitaka/an/an11/an11.016.than.html |title=AN 11.16: Metta (Mettanisamsa) Sutta |accessdate=2007-12-16 |format= |work=}}</ref> Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation. [[Hypnotherapy]], self hypnosis and guided imagery can be effective in not only falling asleep and staying asleep; they can also help to develop good sleeping habits over time. Visualizing can be effective in taking the mind away from present day anxieties and towards a more relaxing place. [[Binaural Beats]] can help people fall asleep faster using special sounds. ==See also== *[[Sleep]] *[[Sleep disorder]] *[[Fatal familial insomnia]] *[[Sleep deprivation]] *[[Delayed sleep phase disorder]] *[[Actigraphy]] ==References== {{reflist}} [[ar:أرق]] [[gn:Kesasy]] [[cs:Insomnie]] [[et:Insomnia]] [[es:Insomnio]] [[fr:Insomnie]] [[ko:불면증]] [[hr:Nesanica]] [[it:Insonnia]] [[he:נדודי שינה]] [[ms:Insomnia]] [[nl:Slapeloosheid]] [[ja:不眠症]] [[no:Søvnløshet]] [[pl:Bezsenność]] [[pt:Insônia]] [[ru:Бессонница]] [[simple:Insomnia]] [[sr:Инсомнија]] [[fi:Unettomuus]] [[sv:Sömnlöshet]] [[vi:Mất ngủ]] [[tr:İnsomnia]] [[uk:Безсоння]] [[zh:失眠]]