There are different types of insomnia, most of which cause people to lay in bed awake, frustrated that they are unable to fall asleep or stay asleep. As a result, they toss and turn, and irritability increases. Insomnia can take various forms, including early morning arousal (difficultly staying asleep), sleeping latency (difficulty falling asleep), fragmented sleep (waking up multiple times during the night), and sleeping very lightly and awakening feeling unrefreshed. Many people with insomnia want to avoid medication because they are concerned about potential addiction, or feeling spacey or drowsy throughout the day.
Sleep-wake cycles are dictated by internal circadian rhythms. These rhythms are strongly influenced by light entering through the eyes, which signals the brain to regulate production of certain hormones including one called melatonin. Circumstances that unnaturally diminish the entrance of light into the eyes can disrupt the natural circadian rhythm, the production of necessary hormones, and therefore, an individual's proper sleep-wake cycle. Such circumstances include blindness and failing eyesight due to aging. Traveling to different time zones and jet lag, as well as working the night shift, disturb the natural circadian rhythm as well.
Insomnia can also be a sign of an underlying medical condition such as depression, an over-active thyroid, high blood pressure, heart disease, asthma, sleep apnea, restless leg syndrome, dementia, or pain disorders. Several lifestyle factors can contribute to sleep disturbance. Keeping a sleep-wake diary is helpful in identifying and modifying these factors, which include: Use of stimulants, including caffeine, nicotine, and ingredients in common drugs such as cold and weight-loss medications. Some people have difficulty falling asleep, others awaken during the night.Use of alcohol. While it may help you fall asleep, alcohol consumption is likely to produce interrupted sleep and is not recommended as an insomnia treatment because of the possibility of addiction.Erratic work hours, such as rotating- or night-shiftsExercise (for example, exercising close to bedtime), or lack of regular exerciseEating habits (for example, eating too late at night)StressExcessive time on the computer or watching TV Treating Insomnia With Lifestyle Changes The most effective and frequently used conventional treatments to establish a restful sleep pattern are behavioral, not medicinal. These include achieving proper "sleep hygiene," as well as making other lifestyle alterations.
Relaxation TechniquesA multidisciplinary team, including medical doctors, specializing in sleep disturbances can train and guide people in such approaches as yoga, meditation, deep relaxation, biofeedback, hypnosis, massage, and/or guided imagery. Practicing one of these techniques within 30 minutes of bedtime is particularly helpful. Simple changes in bedtime routine may also be effective. These include taking a warm bath, listening to soothing music, and drinking warm milk. AcupuncturePositive effects of the use of this ancient Chinese practice have been shown; however, more proof is needed before the World Health Organization will recommend acupuncture as an effective treatment for insomnia. But some reports do suggest a success rate for the treatment of insomnia as high as 90%. A typical protocol is to receive acupuncture treatments weekly until a normal sleep pattern is achieved, followed by maintenance sessions. However, a licensed and certified acupuncturist will determine the most appropriate treatment regimen for each individual. ExerciseRegular exercise is an excellent way to regulate circadian rhythms and the sleep-wake cycle. It is best performed some time prior to dinner, as exercising too close to bedtime can make it difficult to fall asleep.
Light TherapyFor night-shift workers suffering from insomnia, light therapy can be quite effective. This therapy involves using very bright lights in the work setting and then, when trying to sleep during the day, doing so in a very dark room while wearing sunglasses. Cognitive TherapyThis behavioral method involves addressing misconceptions and unrealistic expectations about both insomnia and the nature of sleep. Some issues addressed during cognitive therapy include napping to compensate for poor sleep at night, anxiety about bedtime, fear of sleeplessness, beliefs about necessary hours of sleep, and attributing insomnia to age, ability to sleep, and/ or possible chemical imbalance. One study found that cognitive behavioral therapy decreased sleep latency by 54%, as compared to 16% with relaxation therapy and 12% with placebo treatment. Treating Insomnia With Herbs and Supplements While some cultures have a long history of using supplements and herbal remedies for the treatment of insomnia, such practices have only gained popularity over the last few decades in the United States and other Western nations. Over this relatively short time, though, certain substances, once popular, have already gone out of favor (for example, L-tryptophan is now off the US market due to instances of a rare muscle disorder) or have been somewhat disappointing in light of the initial attention they received (see melatonin below). Those that hold the most promise are:
Valerian RootThe most promising of the botanicals seems to be valerian root (Valerian officianalis). Valerian root is classified as generally recognized as safe in the US for food use. Short term studieslasting up to two weekssuggest success in treating some types of insomnia, particularly those related to anxiety, nervousness, or stress, such as a fitful, restless sleep with frequent arousals. Some questions remain, though, including: Should valerian be taken indefinitely or only until the cycle of insomnia is broken? Is valerian safe to take for a long period of time? Some people have had success with valerian for several types of insomnia. The dose recommended by Germany's Commission E (a governing body that reviews the safety and efficacy of herbal supplements) is 2000-3000 millgrams (mg) of valerian root extract per day either in one dose or three divided doses. Studies have also found success with 400 mg a night. Some doctors recommend the latter, lower dose. LavenderEither sprayed as a mist or used in another form of aromatherapy, lavender aids in a more complete night's sleep, particularly in the elderly. Lavender flower (Lavandula augustifolia) is approved in Germany for oral use as a tea to help soothe the person with insomnia and improve sleep patterns.
Lemon BalmValerian is thought to be particularly successful when used in conjunction with lemon balm (Melissa officianalis). Lemon balm is approved in both Germany and Great Britain to improve sleep disturbances. When used alone, it should be taken as a loose-leaf tea (1.5-4.5 grams per cup of hot water) or dried extract in a capsule (300-900 mg). When used in conjunction with valerian root, though, as little as 160-300 mg of lemon balm extract has been shown to enhance the effects of valerian. Other HerbsOther herbs approved in both Germany and Great Britain for mild to moderate sleep disturbances include: Passion Flower (Passiflora incarnata)This is used particularly for restless sleep related to nervousness or anxiety. Recommended dose: two grams of the dried extract at bedtime in combination with lemon balm and valerian root Chamomile Flower (Matricaria recutita)This is used for mild sleep disturbances. Recommended dose: three grams of the tea before going to sleep Hops (Humulus lupulus)This is used particularly for restless sleep related to nervousness and anxiety. Recommended dose: 300-500 mg of dried extract capsules or tea with valerian root Orange Peel (Citrus aurantium)This is used for transient sleeplessness in both children and adults. Recommended dose: 2 grams of tea in boiled water
Other Substances to Treat Insomnia Prescription Sleep Medications Long-term use of sleeping pills is not recommended, as addiction is likely, and more research needs to be done on safety and effectiveness. For temporary relief of insomnia, the following medications may be prescribed: Short-acting sedative-hypnotics (non-benzodiazepines) Zopidem (Ambien)Zaleplon (Sonata)Eszopiclone (Lunesta) Melatonin receptor agonists (used for sleep latency but not effective for fragmented sleep) Ramelteon (Rozerem) Benzodiazepines (tranquilizers) Flurasepam (Dalman)Temazepam (Restoril)Estazolam (ProSom) The National Sleep Foundation recommends that people taking sleep medication begin with the lowest possible dose that is effective, use the drugs on a short-term basis, and take the drugs intermittently if they are using them on a long-term basis. In certain situations, taking antidepressant medications like Trazodone or Remeron, which have sedating effects, may be very beneficial for patients with insomnia. Nonpharmacologic Insomnia Treatments MelatoninThis neurotransmitter is secreted by the pineal gland and it regulates the sleep cycle. Melatonin is secreted at night, and the secretion is suppressed by bright light during the day. When melatonin secretion is not synchronized with the light-dark cycle, sleep disturbances occur. Frequently touted as a valuable supplement for insomnia, melatonin has shown only mixed results.
Melatonin has been valuable for some people who do not fall asleep easily, as well as for temporary sleep disturbances from a change in schedule (daytime work to nighttime) or sudden disruption of the circadian rhythm as with jet lag. Melatonin may also be helpful for people on a certain class of medications called beta-blockers, used for high blood pressure and heart disease. This supplement is not effective in the elderly, but does work for people with schizophrenia who frequently suffer from insomnia. The effects of melatonin are very individual. Speak with your doctor if you would like to try it, particularly because there are certain circumstances in which it should not be used until more information is available: pregnancy, breast-feeding, autoimmune disorders, leukemia, and lymphoma. The dose of melatonin recommended for insomnia is 1-3 mg per day. However, as little as 0.3 mg per day has induced improvement in sleep in some people. Side effects from melatonin are generally not seen if less than 1 mg/day is taken, while more than 5 mg/day can exacerbate sleep disturbances. Given the information available regarding melatonin, some doctors recommend taking it before going on a trip that involves a change in time zone. In this case, start 2-3 days before leaving and take for 2-3 days after arriving at the new destination.
Vitamin B12Like melatonin, vitamin B12 is useful for some people and not for others. It is thought to help reestablish a disrupted circadian rhythm and normalize levels of stress hormones. Therefore, it may be helpful for stress- or anxiety-related insomnia as well as short, situational insomnia from jet lag or a recent change from day to night work. MagnesiumSome studies suggest that magnesium may be useful for insomnia related to restless leg syndrome and for reduction of the amount of anesthetic needed in the case of surgery. How these two facts translate into induction of sleep with other types of insomnia, though, is unclear. Herbs That Induce Insomnia In addition to caffeine, excessive alcohol, and particular medications, certain herbs sold over the counter can induce wakefulness. These include ginseng, ephedra, yohimbe, and cola nut. The hormonal supplement DHEA may also contribute to insomnia. Putting Insomnia to Rest Insomnia is a common problem that results not only in personal frustration and discomfort, but also is associated with decreased work performance, lost productivity, accidents, and hospitalization. Treatment for insomnia must be specific to the individual to achieve optimal results. Prescription medications (sleeping pills) may be used to achieve short-term results. However, nonprescription treatments are commonly recommended and inexpensive, and also are effective. Talk with your doctor about several strategies that may be combined to help you find relief from problems with sleeping, and to assist you in getting a restful, complete nights sleep.
RESOURCES: American Insomnia Association http://www.americaninsomniaassociation.org National Sleep Center http://www.sleepfoundation.org CANADIAN RESOURCES: Better Sleep Council Canada http://www.bettersleep.ca/ Canadain Sleep Societyhttp://www.css.to/ References: Bain KT. Management of chronic insomnia in elderly persons. Am J Geriatr Pharmacother. 2006 Jun;4(2):168-92. Review. Becker PM. Pharmacologic and nonpharmacologic treatments of insomnia. Neurol Clin. 2005 Nov;23(4):1149-63. Review. Mayers AG, Baldwin DS. Antidepressants and their effect on sleep. Hum Psychopharmacol. 2005 Dec;20(8):533-59. Review. Ringdahl EN, Pereira SL, Delzell JE Jr. Treatment of primary insomnia. J Am Board Fam Pract. 2004;17:212-219. World Health Organization. Diseases and disorders that can be treated with acupuncture. Traditional Chinese Medicine and Acupuncture Health Information Organization website. Available at: http://tcm.health-info.org/WHO-treatment-list.htm. Accessed August 20, 2007. Last reviewed October 2007 by Marcin Chwistek, MD Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.