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Look Up > Conditions > Insomnia
Insomnia
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Laboratory Tests
Pathology/Pathophysiology
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
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 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, electro-oculogram (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 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, psychotherapy, and relaxation methods may 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. 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. 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. 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. 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. Dose is 15 to 30 drops ( to 1 ml) tincture one to three times a day, or to ml of concentrated liquid extract three times a day.
  • St. John's wort (Hypericum perforatum): for insomnia with anxious depression; dose is 15 to 60 drops ( 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 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

May be effective at treating both insomnia and some of its underlying causes.


Massage

May be beneficial for its systemic relaxing properties.


Patient Monitoring

Chronic insomnia and exhaustion increases 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 with 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 comorbid condition, 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.


Pregnancy

Insomnia usually occurs in the later months of pregnancy when the mother's size and need to urinate disrupt sleep. The best treatment is naps during the day.


References

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:422, 431.

Bravo SQ, et al. Polysomnographic and subjective findings in insomniacs under treatment with placebo and valerian extract (LI 156 ). Proceedings of the Second International Congress on Phytomedicine, Munich. Eur J Clin Pharmacol. 1996;50:552.

DreBring H. Insomnia: Are valerian/balm combinations of equal value to Benzodiazepine? Therapiewoche. 1992;42:726.

Emser W. Phytotherapy of insomnia—a critical overview. Pharmacopsychiatry. 1993;26:150.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.

Goroll, Allan H, ed. Primary Care Medicine. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1995.

Rakel RE, ed. Conn's Current Therapy. 50th ed. Philadelphia, Pa: WB Saunders Co; 1998.


Copyright © 2000 Integrative Medicine Communications

This publication contains information relating to general principles of medical care that should not in any event be construed as specific instructions for individual patients. The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. The reader is advised to check product information (including package inserts) for changes and new information regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.