Definition
Insomnia is a disorder or a symptom of another condition, not a disease. It is the persistent inability or difficulty with falling or staying asleep. It frequently impairs daytime functioning. At some time during the year, approximately one-third of adults suffer from some form of insomnia.
Etiology
Insomnia may have distinct underlying physical and/or mental causes, or it may have no discernable cause.
In idiopathic insomnia (up to 50% of all insomnia cases), the patient's polysomnogram is usually normal.
Transient situational insomnia is caused by work or school stress or family illness.
Other causes of insomnia include the following:
- Substance abuse—caffeine, alcohol, recreational drugs, long-term sedative use, stimulants, decongestants, bronchodilators
- Disruption of circadian rhythms—shift work/travel across time zones
- Menopause—prevalent in 30% to 40% of menopausal women
- Elderly—normal decrease in depth, length, continuity of sleep
- Medical illness—gastroesophageal reflux disease (GERD), fibromyalgia, hyperthyroidism, dementia, arthritis, and other painful conditions
Risk Factors
- Age—elderly are more affected
- Night-time occupation
- Travel crossing time zones
- Substance abuse, including caffeine
- Asthmatics—use of bronchodilators
Signs and Symptoms
- Impaired sleep onset
- Impaired sleep maintenance (e.g., frequent waking)
- Early-morning waking
- Subjective sense of unsatisfying sleep
- Daytime drowsiness and impaired functioning
- Anticipatory anxiety
Differential Diagnosis
- Psychiatric—character disorder, depression, anxiety, psychosis
- Medical causes—thyroid disorders, gastric and peptic ulcers, chronic pain, cardiopulmonary dysfunction, urinary frequency, Parkinson's disease, and dementia
- Sleep apnea syndrome
- Narcolepsy
- Nocturnal myoclonus
Diagnosis
Physical Examination
Surgical and medical history and physical examination are essential diagnostic tools, as the patient may not appear tired.
Laboratory Tests
Tests rule out a differential diagnosis or underlying causes (e.g., toxic screen test for substance abuse, thyroid-stimulating hormone test for hyperthyroidism).
Pathology/Pathophysiology
Rapid-eye-movement (REM) sleep and non-rapid-eye-movement (NREM) sleep changes from its normal pattern in people with sleep disorders but rarely for those with idiopathic insomnia.
Other Diagnostic Procedures
Polysomnogram can determine biologic causes; includes electroencephalogram, electrocardiogram, respiration, electrooculogram (eye movement), electromyogram (muscle tone), and blood oxygen saturation.
Treatment Options
Treatment Strategy
- Identify initiating stressor(s),
- rule out underlying illnesses, and develop a strategy to help the patient cope with and alleviate the symptoms.
- Comorbidity must be determined and treated first to avoid inaccurate or even harmful treatment (e.g., benzodiazepine for a patient with sleep apnea).
Also, recommend:
- Maintain good sleep hygiene.
- Keep a regular sleep/wake schedule.
- Exercise early in the day, not in the evening.
- Do not nap. However, some people who become overtired may actually sleep better if they take a nap.
- Set up optimal conditions for sleep and have relaxing bedtime rituals.
Drug Therapies
For idiopathic insomnia:
- Pharmacologic—sedative-hypnotic compounds reduce sleep latency and increase continuity.
- Benzodiazepine (BZD) class (triazolam 0.125 mg/day, clonazepam 0.5 mg/day, or flurazepam 15 mg/day with anxiety); use the lowest dose with elderly; side effects—daytime sleepiness, ataxia, addiction; do not use with alcohol or for sleep apnea; withdraw slowly.
- Tricyclic antidepressants (Elavil)—amitriptyline (10 to 100 mg at bedtime)
Complementary and Alternative Therapies
Herbs may be effective for treating both short term and chronic insomnia. Nutrition can be an important adjunctive treatment.
Mind-body treatments, such as yoga therapy, psychotherapy, and relaxation techniques/methods are found to be helpful.
Nutrition
- Calcium/magnesium: regulate relaxation, especially with muscle tension and physical restlessness, 500/250 Ca/Mg bid
- B-complex: B vitamins are depleted under stress; they may be stimulating in certain individuals, so take in the morning.
- 5-HTP is a form of tryptophan now available which is particularly helpful for difficulty staying asleep. 5-HTP increases serotonin levels. The dose is 50 mg before bed. 5-HTP will help within one week if it will be helpful at all. Dietary sources of tryptophan include turkey, eggs, fish, dairy products, bananas, and walnuts. (Tryptophan as a supplement was removed from the market after a contaminant caused severe side effects.)
- Melatonin: manufactured in the pineal gland, from tryptophan, is responsible for appropriate circadian rhythms and is used to prevent jet lag. The dose is 1 to 3 mg before bed. Note that a lower dose may be effective when a higher dose is not.
- Niacinamide: muscle relaxant, gentle tranquilizing effects. The dose is 70 to 280 mg/day, either in divided doses during the day (anxiolytic), or at bedtime.
Herbs
Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted. The herbs are listed in order of increasing strength; use the gentlest herb that is effective.
- Chamomile (Chamomilla recutita): mild sedative, calms gastric upset. One cup of chamomile tea before bed is often all that is needed for mild insomnia. In a few patients, chamomile may cause gastric upset.
- Lemon balm (Melissa officinalis) alone, or in combination with catnip (Nepeta cataria): nervous sleeping disorders and mild digestive complaints; one cup tea or 30 to 60 drops tincture one to three times a day.
- Passionflower (Passiflora incarnata): the aerial parts of passionflower are a very effective herbal remedy for insomnia taken 2 to 4 ml one-half hour before bedtime.
- Valerian (Valeriana officinalis): sedative, anodyne, bitter. Side effects of too high a dose include nausea and/or grogginess. Traditionally used in combination with passionflower and hops (Humulus lupulus) for treatment of acute stress. Persons with depression should avoid hops. The dose is equal parts herb in 1 cup one to three times a day, or tincture 30 to 60 drops one to three times a day.
- Kava kava (Piper methysticum): spasmolytic, anxiolytic, sedative; very effective for short-term management of stress and insomnia. Should not be used for more than three months without medical supervision. The dose is 15 to 30 drops (½ to 1 ml) tincture one to three times a day, or ¼ to ½ ml of concentrated liquid extract three times a day.
- St. John's wort (Hypericum perforatum): for insomnia with anxious depression; the dose is 15 to 60 drops (½ to 2 ml) tid, or 250 mg tid of herb or herb extract for depression. Side effects may include skin rash, photosensitivity, and gastric upset. It may take four to six weeks to become effective.
- Jamaica dogwood (Piscidia piscipula): Jamaican dogwood is a powerful remedy for insomnia, particularly when the sleeplessness is due to nervous tension and pain. Taken 1 to 2 ml just before bedtime, Jamaican dogwood is arguably the strongest herbal anodyne for sleeplessness. Jamaican dogwood combines well with passionflower, valerian, kava, and St. John's wort.
- Essential oils (three to five drops added to a bath) may be effective as part of a bedtime ritual. Commonly used herbs are lavender (Lavandula angustifolia), rosemary (Rosmarinus officinalis), and chamomile (Chamomilla recutita).
Homeopathy
An experienced homeopath should assess individual constitutional types and severity of the disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy, every one to four hours until acute symptoms resolve.
- Arsenicum alba for insomnia caused by anxiety (especially about their health), especially in perfectionists who develop panic attacks
- Nux vomica for insomnia from overuse of stimulants, caffeine, drugs or tobacco, especially in competitive, aggressive people
- Coffea cruda for insomnia from a racing mind, especially if the stress is adjusting to a positive event Ignatia imara for insomnia (or excessive sleeping) after grief
Acupuncture
Acupuncture has been found effective at treating both insomnia and some of its underlying causes.
Massage
Massage has been found beneficial for its systemic relaxing properties.
Patient Monitoring
Chronic insomnia and exhaustion increase risks for accidents and the likelihood of comorbid conditions.
Other Considerations
Prevention
Establishing good sleep habits is the best method to avoid insomnia when there is no comorbidity or complicating factors. A healthy diet and regular exercise also help to prevent insomnia and alleviate stress. Alcohol disrupts the quality of sleep and regular use before bed should be avoided.
Complications/Sequelae
- BZDs can cause oversedation if used for substance abuse or sleep apnea patients.
- Elderly patients need special attention to insomnia treatment. Education about the need for less sleep is important. Pain medication needs to be adequate to permit good sleep. However, caution in not oversedating is important to avoid falls and other complications.
Prognosis
Without comorbidity, or with successful treatment of the comorbid conditions, most patients recover within a few weeks or after the stressful event has been resolved. Chronic insomnia with sedative dependence can take years to overcome.
Regards,
INTEGRATIVE MEDICINE
