Insomnia

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Insomnia
ICD-10	F51.0, G47.0
ICD-9	307.42, 307.41, 780.51, 780.52
DiseasesDB	26877
MedlinePlus	000805
MeSH	D007319

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Synonyms and keywords: Insomnia disorder

Overview

Insomnia is a sleep disorder characterized by an inability to sleep and/or inability to remain asleep for a reasonable period. Insomniacs typically complain of being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and nonorganic insomnia constitute a sleep disorder.

Classification

Types of insomnia

Three types of insomnia exist: transient, acute, and chronic

1. Transient insomnia lasts from one night to a few weeks. Most people occasionally suffer from transient insomnia due to such causes as jet lag or short-term anxiety. If this form of insomnia continues to occur from time to time, the insomnia is classified as intermittent.
2. Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.
3. Chronic insomnia is regarded as the most serious; persists almost nightly for at least a month.

Patterns of Insomnia

The pattern of insomnia often is related to the etiology.[3]

1. Initial insomnia - difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
2. Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with pain syndromes or medical illness.
3. Terminal (or late) insomnia - early morning waking. Characteristic of Clinical depression.

Causes

Insomnia can be caused by:

• Psychoactive drugs or stimulants, including certain medication, herbs, caffeine, cocaine, ephedrine, amphetamines, methylphenidate, MDMA, methamphetamine and modafinil
• Hormone shifts such as those that preceed menstruation and those during menopause
• Psychological problems like fear, stress, anxiety, emotional or mental tension, work problems, financial stress, unsatisfactory sex life
• Mental Disorders such as clinical depression, bipolar disorder, general anxiety disorder, sleep disorders
• Disturbances of the circadian rhythm such as shift work and jet lag
• Certain neurological disorders, brain lesions, or a history of Traumatic brain injury
• Medical conditions such as Hyperthyroidism and Wilson's Syndrome
• Drugs: Acamprosate calcium, acetaminophen, Atovaquone, caspofungin acetate, Leuprolide, levofloxacin, Oxandrolone, Nandrolone, Pirfenidone, Rasagiline, Secobarbital sodium, Sulfasalazine, Trifluoperazine, Varenicline.

Insomnia also sometimes occurs for no apparent reason. 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 months or a year after the death, if they are not grieving correctly (pretending they are over it when they are not).

Acute

• Environment changes
• Extremes of temperature
• Illness
• Injury
• Light
• Noise
• Poor bed
• Situational stress

Chronic

• Angina
• Anxiety
• Arthritis pain
• Asthma
• Benign prostatic hyperplasia
• Bipolar Disorder
• Caffeine
• Cancer pain
• Chronic Fatigue Syndrome
• Chronic Obstructive Pulmonary Disease (COPD)
• Chronic Renal Disease
• Cluster headaches
• Congestive Heart Failure
• Dementia
• Depression
• Diabetes Mellitus
• Drugs- Armodafinil, Clomifene, Diflunisal, Eculizumab, Efavirenz, Fluvoxamine, Levofloxacin, Naltrexone, Ofloxacin, Oxymetazoline, Paroxetine, Phentermine, Ribavirin, Rifaximin, Sulindac, Tacrolimus, Temozolomide, Thalidomide, Topiramate, Varenicline
• Fibromyalgia
• Gastroesophageal Reflux Disease (GERD)
• Hyperthyroidism
• Inflammatory Bowel Disease (IBD)
• Mania
• Menopause
• Nocturnal panic disorder
• Other movement disorders
• Pain
• Parkinson's Disease
• Peptic Ulcer Disease
• Poor sleep hygiene
• Posttraumatic Stress Disorder
• Pregnancy
• Pruritis
• Psychosis
• Reflux esophagitis
• Schizophrenia
• Seizures
• Sleep Apnea
• Uremia
• Urinary Tract Infection (UTI)

Other

• Circadian rhythm disorders
• Idiopathic insomnia
• Drugs
  • Alemtuzumab
  • Amoxicillin
  • Amobarbital sodium
  • Butorphanol
  • Desmopressin
  • Dapsone
  • Lacosamide
  • Milnacipran hydrochloride
  • Vilazodone
  • Meropenem
  • Ramelteon
  • Terbutaline
• Narcolepsy
• Obstructive sleep apnea
• Periodic limb movement disorder
• Prion fatal familial insomnia
• Psychophysiologic insomnia
• REM-behavior disorder
• Restless leg syndrome (RLS)
• Sleep state misperception

Differential Diagnosis

• Breathing-related sleep disorders
• Delayed sleep phase and shift work types of circadian rhythm sleep-wake disorder
• Narcolepsy
• Normal sleep variations
• Parasomnias
• Restless legs syndrome
• Situational/acute insomnia
• Substance/medication-induced sleep disorder, insomnia type

Epidemiology and Demographics

Prevalence

The prevalence of insomnia disorder is 10,000-20,000 per 100,000 (10%-20%) in the primary care setting.

According to the U.S. Department of Health and Human Services in year 2007, approximately 64 million Americans suffer from insomnia each year. Insomnia tends to increase with age and affects about 40 percent of women and 30 percent of men. The average American gets 7 hours of sleep, instead of the 8 to 10 hours recommended by doctors. Children however are recommended more than 8 hours.

Risk Factors

• Advancing age
• Anxiety or worry-prone personality
• Chronic daily stress
• Cognitive styles
• Familial disposition
• Fear of not sleeping
• Female gender
• High altitude
• Increased arousal
• Irregular sleep scheduling

• Excessive caffeine use
• Irregular sleep schedules

• Light
• Major life events (e.g., illness, separation)
• Noise
• Poor sleep habits
• Poor sleep hygiene practices
• Tendency to repress emotions
• Uncomfortably high or low temperature

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.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Insomnia Disorder

“

A.A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: 1.Difficulty initiating sleep.(In children, this may manifest as difficulty initiating sleep without caregiver intervention.) 2.Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.): 3. Early-morning awakening with inability to return to sleep. AND B.The sleep disturbance causes clinically significant distress or impairment in social, occupational,educational, academic, behavioral, or other important areas of functioning. AND C.The sleep difficulty occurs at least 3 nights per week. AND D.The sleep difficulty is present for at least 3 months. AND E.The sleep difficulty occurs despite adequate opportunity for sleep. AND F.The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia). AND G.The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). AND H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia. Specify if: With non-sleep disorder mental comorbidity, including substance use disorders With other medical comorbidity With other sleep disorder Specify if: Episodic:Symptoms last at least 1 month but less than 3 months. Persistent: Symptoms last 3 months or longer. Recurrent: Two (or more) episodes within the space of 1 year. Note:Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but otherwise meeting all criteria with regard to frequency, intensity, distress, and/or impairment)should be coded as an other specified insomnia disorder.

”

Insomnia versus poor sleep quality

Poor sleep quality can occur as a result of sleep apnea or major 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 hypothalamus and pituitary causing excessive release of cortisol which can lead to poor sleep quality.

Nocturnal polyuria or excessive nighttime urination can be very disturbing to sleep. Nocturnal polyuria can be nephrogenic (related to kidney disease) or it may be due to prostate enlargement or hormonal influences. 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. Excessive thirst or the use of diuretics can also cause these symptoms.

Treatment

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 tablets and other sedatives 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 benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.

In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was insignificantly more than for antidepressants. Benzodiazepines had an insignificant tendency for more adverse drug reactions.

Benzodiazepines

Main article: Benzodiazepine

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABA_A receptor. This includes drugs such as temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long periods of time.

Non-benzodiazepines

Main article: Nonbenzodiazepine

Nonbenzodiazepine prescription drugs, including the nonbenzodiazepines zolpidem(Stilnoct) and zopiclone(Imovane), are more selective for the GABA_A receptor 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 psychological dependence and physical dependence, and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.

Antidepressants

Main article: Antidepressants

Some antidepressants such as mirtazapine, trazodone and doxepin 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.

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.

Antihistamines

The antihistamine diphenhydramine is widely used in nonprescription sleep aids, 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.

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.

Other substances

Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective. Cannabis has also been suggested as a very effective treatment for insomnia.

Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.

Insomnia may be a symptom of magnesium deficiency, or lower magnesium levels. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.

Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal.

Non-medicinal, complimentary and alternative medicine

Recent research has shown that cognitive behavior therapy can be more effective than medication in controlling insomnia [4]. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep.

Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; 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, and making sure to get up early in the morning and to retire to bed at a reasonable hour.

Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness. Horlicks is marketed as a sleeping aid.

Many believe that listening to slow paced music will help insomniacs fall asleep.

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.

Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, 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. 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, Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.

See also

• Chronic colestites, also known as "total insomnia"
• Fatal familial insomnia
• Sleep deprivation
• Delayed sleep phase disorder
• Actigraphy

References

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