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Insomnia
medical conditions

Insomnia

Explore the available health information, treatment context, and integrative evidence for Insomnia.

Background
  • Insomnia is difficulty in falling asleep, staying asleep, and waking up too early in the morning. It is a common health problem that can cause excessive daytime sleepiness and a lack of energy. Long-term insomnia can cause an individual to feel tired, depressed or irritable, have trouble paying attention, learning, and remembering, and not be able to perform fully on the job or at school. Severe insomnia can result in neurochemical (brain chemical) changes that may cause problems such as depression and anxiety, further complicating the insomnia.
  • Insomnia increases sleep latency, or the length of time that it takes to go from full wakefulness to falling asleep. During the daytime, a sleep latency of 15-25 minutes is considered normal.
  • Insomnia is classified as transient (occasional), mild, and severe, depending on how often it occurs and for how long. Chronic insomnia is defined as having symptoms at least three nights per week for more than a month. Insomnia that lasts for less than a month is known as short-term, or acute insomnia.
  • Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30-50% of the general population of the United States has been affected at one time or another by acute insomnia, and 10% have chronic (long-term) insomnia.
  • Insomnia affects all age groups, but its prevalence tends to increase with age. Insomnia affects approximately 40% of women and 30% of men at any given time. The average American gets seven hours of sleep nightly, instead of the eight to ten hours recommended by doctors.
Risk Factors and Causes
  • Risk factors associated with developing insomnia include stress, depression, pregnancy, menopause, having frequent, major shifts in work hours, and traveling long distances with time changes (jet lag). Stimulant drinks containing caffeine may increase the risk of developing insomnia, as do certain prescription and non-prescription medications, including nasal decongestants (including pseudoephedrine or Sudafed®), weight loss drugs (including phentermine and sibutramine), amphetamines, and some antidepressants (including bupropion or Wellbutrin®), asthma (including albuterol or Ventolin®), and blood pressure medications (including beta blockers).
  • Psychological: The most common psychological problems include anxiety, stress, and depression. In fact, insomnia may be an indicator of depression. Many people will have insomnia during the more severe phases of a mental illness (such as in mania of bipolar disorder). Mania causes the excessive release of neurochemicals such as dopamine. Feelings of grief, depression or major depression, worry, anxiety or stress, exhilaration or excitement all may cause insomnia, either acute or chronic, depending upon the individual.
  • Physiological: Medical conditions can cause insomnia, such as chronic (long-term) pain (including arthritis, fibromyalgia, cancer), enlarged prostate, cystitis (common in women), over-active thyroid glands, congestive heart failure (CHF), gastroesophageal reflux disease (GERD, heartburn), chronic obstructive pulmonary disease (COPD), gastrointestinal disorders such as diarrhea, ulcers, or irritable bowel syndrome (IBS), and nervous system diseases, such as Alzheimer's disease or Parkinson's disease. These conditions cause imbalances and changes in circadian rhythm (24 hour light and dark balance) and sleep/wake balance.
  • Medications: Certain prescription and non-prescription medications may also cause acute or chronic (long-term) insomnia. If the insomnia is related to a medication side effect, a normal sleep/wake pattern should be achieved shortly after discontinuing the medication. Medicines that stimulate brain neurochemistry may cause insomnia. These include nasal decongestants, weight loss drugs, amphetamines (including methamphetamine or crystal meth), some antidepressants, cocaine, and some asthma and heart medications. Caffeine, alcohol, and nicotine may also contribute to insomnia by altering brain chemistry, thereby disrupting the normal sleep/wake cycle. The abrupt discontinuation of alcohol (in alcoholics) can also contribute to insomnia. The abrupt stopping of medications (such as sleeping pills, hypnotics, anti-anxiety drugs, and antidepressants) can cause acute insomnia.
  • Sleep apnea: Sleep apnea may also cause insomnia. Sleep apnea means cessation of breath, and is characterized by repetitive episodes of upper airway obstruction (mouth, nose, throat) that occur during sleep, usually associated with a reduction in blood oxygen saturation. Airway muscles relax and collapse when asleep, causing them to become obstructed (blocked) at several possible sites, resulting in snoring. The upper airway can be obstructed by excess tissue in the airway, such as large adenoids (tonsils) or a large tongue. Another site of obstruction can be the nasal passages. Sleep apnea can be a serious condition, and can result in excessive daytime sleepiness, loud snoring, morning headaches, hypertension (high blood pressure), weight gain, irritability and personality changes, depression, difficulty concentrating, excessive perspiring during sleep, heartburn, reduced libido (sexual drive), nocturia (frequent urination at night), restless sleep, and snorting, gasping, or choking.
  • Other common causes: A disruptive bed partner with loud snoring or periodic leg movements (restless leg syndrome or RLS) may also cause insomnia. Nocturnal polyuria, or excessive nighttime urination, can be very disturbing to sleep. Excessive thirst or the use of diuretics can also cause these symptoms. Not getting enough light during the day can cause the natural circadian rhythm and the sleep/wake cycle to be disturbed, causing insomnia. Jet lag, shift work, wake-sleep pattern disturbances, bed or bedroom not conducive to sleep, aging, excessive sleep during the day, and excessive physical or intellectual stimulation at bedtime can all contribute to acute or chronic insomnia.
  • Causes in infants:
    Most newborn babies wake several times during the night, but by the age of six months they typically sleep through the night. At one year, babies will sleep an average of about 16 hours in every 24. Two to three hours of this sleep will be during the day. Causes of sleeplessness in infants may include a desire for parental attention, infantile colic or other digestive problems such as indigestion, hunger, teething, and fever or other illness such as a cold or influenza.
Signs and Symptoms
  • The main signs and symptoms of insomnia are trouble getting, staying asleep, or waking early, followed by a distinct feeling of fatigue (tiredness) the following day. Most often, daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include anxiousness, irritability, fatigue (tiredness), poor concentration and focus, difficulty with memory, impaired motor coordination, irritability and impaired social interaction, and motor vehicle accidents because of fatigued, sleep-deprived drivers.
Diagnosis
  • Medical history: A doctor will ask the individual experiencing insomnia questions to evaluate the medical history. Questions investigate mental health problems, medications (supplements, prescription and non-prescription), history of pain, leisure habits, work and home situation, and others.
  • Sleep history: The doctor will also inquire about the individual's sleep history. Questions inquire about length and severity of the sleeping problem, routines before sleeping, snoring, and noise levels.
  • Physical exam: The doctor will also give the individual a full physical exam, including blood tests for conditions that may interfere with sleep including thyroid problems.
  • Sleep study (Polysomnogram): A polysomnogram is a recording of the breathing, movements, heart function, and brain activity during sleep. For this study, the individual sleeps overnight at a sleep center or hospital. A sleep study will be recommended if there are signs of sleep apnea or restless legs syndrome (RLS).
  • Other: The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness. It asks questions about the chances of dozing off during various daily functions such as watching TV, sitting and reading, or driving a car. 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. Actigraphs measure day-to-day activity of an individual, recording movement being made during waking and sleeping hours along with light, sound, and temperature. Actigraphy is useful for assessing daytime sleepiness in situations where a laboratory sleep latency test is not appropriate. Actigraphy is used to clinically evaluate insomnia, circadian rhythm sleep disorders, excessive sleepiness, and restless leg syndrome. It is also used in the assessing of the effectiveness of treatments for these disorders.
Complications
  • Whatever the reason for sleep loss, insomnia can affect people both mentally and physically. The impact can build up over time.
  • People with chronic insomnia are more likely than others to develop psychiatric problems, such as depression or an anxiety disorder. Additionally, lack of sleep slows problem-solving skills. Long-term sleep deprivation may be due to conditions such as sleep apnea, which increase the severity of chronic diseases (including high blood pressure and diabetes).
  • Insufficient sleep can also lead to serious or even fatal accidents. According to the National Highway Traffic Safety Administration, more than 100,000 crashes each year are due to drivers falling asleep at the wheel.
  • In a recent study, scientists discovered that youngsters who snore nightly scored significantly lower on vocabulary tests than those who snore less often.
Treatment
  • Insomnia is often caused by another disease or psychological problem. In any such case, it is important that the underlying condition be treated to eradicate the insomnia. A psychologist or psychiatrist may be able to determine if psychological issues are causing the insomnia. A physical examination may help determine if the insomnia is caused by other health issues. Recent research has reported that cognitive behavior therapy can be more effective than medication in controlling insomnia. In this therapy, patients are taught improved sleep habits and are counseled on counter-productive thoughts about sleep. For success with this type of therapy, the individual may need to see a therapist weekly over two to three months.
  • The U.S. Food and Drug Administration (FDA) has issued warnings for all sedative-hypnotic drugs used for sleep regarding the potential for adverse events. Anaphylaxis and severe facial angioedema (swelling) can occur the first time a sleep product is taken. Complex sleep-related behaviors may include sleep-driving (driving while not fully awake, and with no memory of driving), making phone calls, and preparing and eating food while asleep.
  • Benzodiazepines: Benzodiazepines are a class of sedative/hypnotic drugs that were once the standard therapy for insomnia. The benzodiazepines used for insomnia include temazepam (Restoril®), flurazepam (Dalmane®), estazolam (ProSom®), and triazolam (Halcion®). Benzodiazepines have the potential of causing psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat. Benzodiazepines may cause depletion of the natural hormone melatonin from the body. Melatonin helps the body regulate sleep/wake cycles and circadian rhythm.
  • Non-benzodiazepines: In recent years, a newer class of sedative hypnotic medications has been developed, often termed the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and less adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien®), zaleplon (Sonata®), and eszopiclone (Lunesta®).
  • Zolpidem (Ambien®, Ambien CR®) may help the individual have a more restful sleep and stay asleep longer. It is typically prescribed for administration at bedtime and may be used when the individual has trouble falling asleep and/or staying asleep. Zaleplon (Sonata®) is generally used in individuals who have trouble falling asleep. It is often taken at bedtime or later, such as when awakening during the night, as long as there are at least four or more hours left to sleep. Eszopiclone (Lunesta®) helps people get to sleep faster and also appears to help the individual stay asleep through the night. The FDA has approved Eszopiclone for patients who have difficulty falling asleep, as well as those who are unable to sleep through the night. Eszopiclone must be taken immediately before bedtime and the individual should make sure that he or she has a full eight hours devoted to sleeping before taking it. As with the other medications, side effects can occur, including daytime drowsiness, dry mouth, and dizziness. Unlike the other medications in this class which are recommended only for use on a temporary basis, Eszopiclone is approved for longer term use (longer than seven days).
  • Melatonin agonists: Ramelteon (Rozerem®) belongs to a new class of drugs called melatonin agonists. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle, also known as the 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. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Ramelteon is approved by the U.S. Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep. These drugs have a relatively mild side effect profile, a lower likelihood of causing morning sedation, and may lack the potential for abuse and dependence. The body regulates back to normal daytime levels of melatonin when it is daylight. Side-effects may include daytime sleepiness, dizziness, and fatigue.
  • Antidepressants: The sedating antidepressant medications most commonly used to help with sleep include trazodone (Desyrel®), amitriptyline (Elavil®), and doxepin (Sinequan®). When used for sleep, these medicines are used in lower doses than when used in the treatment of depression. Benefits of these antidepressants include a lack of addictive properties or tolerance and the added benefit of providing some analgesic (pain relieving) benefit. Side effects include dry mouth, blurred vision, a "hangover" in the morning, constipation, urinary retention, and nausea.
  • Over The Counter (OTC) sleep aids: Antihistamines may be used short-term for insomnia. Diphenhydramine (Benadryl®) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl®, Nytol®, Sominex®) or in combination with other OTC items such as acetaminophen (Tylenol PM®). Combining diphenhydramine with acetaminophen has the added benefits of not only helping the individual sleep better, but providing pain relief also. OTC sleep aids are not intended for long term use, because dependency can develop. Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation. Also, many OTC products contain the same ingredients, such as acetaminophen which can be purchased in many combinations. Tylenol® and Tylenol PM® both contain acetaminophen and should not be taken together. Acetaminphen has been reported to cause severe liver damage in overdose. It is recommended by healthcare professionals to not take more than four grams of acetaminophen daily.
  • Atypical antipsychotic drugs: Other medications used off-label for insomnia are low doses of the atypical antipsychotics, including quetiapine (Seroquel®), mirtazapine (Remeron®), and olanzapine (Zyprexa®). Antipsychotics appear to work by blocking the action of the neurotransmitters serotonin and dopamine, thus producing a tranquilizing, sedating, and antipsychotic effect. Atypical antipsychotics may increase the incidence of extrapyramidal side effects (abnormal movements, muscle stiffness/shaking, or an uncomfortable restless feeling) and weight gain in higher doses. More serious side effects may include diabetes and high cholesterol and triglycerides.
  • Others: Requip® (ropinirol) may be used if restless leg syndrome (RLS) is present. Restless legs syndrome (RLS) causes a powerful urge to move the legs. The legs become uncomfortable when lying down or sitting. Some people describe it as a creeping, crawling, tingling or burning sensation. Moving makes the legs feel better, but not for long. RLS occurring at night can disrupt sleeping patterns and cause insomnia. Common side effects associated with Requip® include nausea, drowsiness, vomiting, and dizziness.
Prevention
  • Exercise: Exercise regularly, at least 30 minutes daily, five days a week. Aerobic exercise and general fitness are important in maintaining good health and preventing insomnia. Exercising within two hours of bedtime may cause trouble falling asleep.
  • Diet: Avoid large meals and excessive fluids before bedtime, as they can cause trouble falling asleep. Healthcare professionals recommend avoiding caffeine, nicotine, beer, wine and liquor six to eight hours before bedtime. Caffeine and nicotine are stimulants to the nervous system and may cause insomnia. Alcohol interferes with normal sleep patterns by disrupting neurotransmitters (nerve chemicals) in the brain that control or regulate sleep. When these neurotransmitters (including dopamine and serotonin) are disrupted, disturbances, such as insomnia, can result. Small amounts of alcohol can cause early sedation or sleepiness, and is often used as a sedative. However, the use of alcohol as an effective sedative can be extremely misleading because the side effects that can result are usually even more harmful and detrimental to the natural sleep cycle. Alcohol can also be associated with sleep apnea.
  • Environment: Controlling the environment, such as light, noise, and temperature, may help prevent insomnia. Night shift workers especially must address these factors.
  • Going to bed at the same time daily helps develop the natural circadian rhythm cycle and the sleep/wake cycle.
  • Other: In order to prevent insomnia, healthcare professionals recommend to establish a regular bedtime, use the bedroom for bedroom activities only, avoid staying in bed for long periods of time while awake, or going to bed because of boredom, take the TV or computer out of the bedroom (too much stimulation), relax by reading, taking a bath, or listening to soothing music before getting to bed, and try to avoid emotional upset or stressful situations prior to bedtime.
  • Infants and children:
    To help infants and children avoid insomnia, healthcare professionals recommend for the parent to avoid being readily available to a child during the night. Otherwise, the child may become dependent on attention and become sleepless if deprived of it. For children who have trouble falling asleep, try to make sure that the child is not disturbed by unnecessary noise. Leaving a radio playing soft music may help cover up disturbing noises. Avoid sending a child to bed as punishment, that can result in poor sleep caused by fear, and never give a child sleeping medicine without consulting a doctor first.
References

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

  • American Academy of Family Physicians. . Accessed April 11, 2009.
  • American Academy of Otolaryngology. . Accessed April 11, 2009.
  • American Academy of Sleep Medicine. . Accessed April 11, 2009.
  • Atkinson G, Davenne D. Relationships between sleep, physical activity and human health. Physiol Behav. 2007;90(2-3):229-35.
    View Abstract
  • National Institutes of Health. . Accessed April 11, 2009.
  • National Sleep Foundation. . Accessed April 11, 2009.
  • Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed April 11, 2009.