Insomnia

The three types of insomnia are acute, transient, and chronic insomnia.

Insomnia is defined as difficulty initiating or maintaining sleep, or both, despite adequate opportunity and time to sleep, leading to impaired daytime functioning. Insomnia may be a cause of or result of poor quality and/or quantity of sleep.

Insomnia is very common. Ninety percent of the general population has experienced acute insomnia at least once. Approximately 10% of the population may suffer from chronic (long-standing) insomnia.

The problem affects people of all ages including children, although it is more common in adults, and its frequency increases with age. In general, women are affected more frequently than men.

Insomnia may be divided into three types based on the duration of symptoms:

• Transient insomnia lasts 1 week or less and may be termed transient insomnia.
• Short-term insomnia lasts more than 1 week but resolves in less than 3 weeks.
• Long-term or chronic insomnia lasts more than 3 weeks.

Insomnia can also be classified based on the underlying reasons for insomnia:

• Sleep hygiene
• Existing health problems or other diseases
• Sleep disorders
• Stress factors

It's important to make a distinction between insomnia and other similar terminology; short duration sleep and sleep deprivation:

• Short-duration sleep: This may be normal in some patients who may require less time for sleep without feeling daytime impairment, the central symptom in the definition of insomnia.
• Sleep deprivation: In insomnia, adequate time and opportunity for sleep are available, whereas, in sleep deprivation, lack of sleep is due to a lack of opportunity or time to sleep because of voluntary or intentional avoidance of sleep.

Insomnia may have many causes and, as described earlier, it can be classified based on the underlying cause.

The International Classification of Sleep Disorders has classified insomnia into multiple categories:

• Adjustment insomnia (acute insomnia): short-term or acute insomnia usually due to stress or environmental changes
• Psychophysiologic insomnia (primary insomnia): prolonged stress with chronic insomnia
• Paradoxical insomnia: little or no sleep at night with rare normal night sleep because of a pattern of consciousness throughout the night, or where near-constant awareness of environmental stimuli occurs
• Insomnia due to a medical condition: insomnia associated with disorders such as advanced chronic obstructive pulmonary disease (COPD), arthritis, cancer, renal disease, fibromyalgia, neurologic problems, Parkinson's disease, and chronic fatigue syndrome
• Insomnia due to mental disorder: depression, schizophrenia, and maniac phase of bipolar illness, for example
• Insomnia due to drug or substance abuse: for example, alcohol abuse, stimulant abuse, caffeine abuse
• Insomnia not due to substances or known physiologic conditions, unspecified: a temporary diagnostic term used for suspected but unproven underlying mental, physiological, or environmental problems
• Inadequate sleep hygiene: proper sleep scheduling, routine use of alcohol, nicotine, and caffeine, frequent daytime napping, using the bed for watching TV, snacking, or reading and/or studying for tests or work-related subjects
• Idiopathic insomnia: long-term insomnia begun in infancy or childhood with no readily identifiable underlying cause
• Behavioral insomnia of childhood: insomnia in children based on adult caregiver observations
• Primary sleep disorders causing insomnia: insomnia due to restless leg syndrome, obstructive sleep apnea/hypopnea (shallow breathing) syndrome, nocturia (need to urinate at night), or circadian rhythm disorders for example

Common situational and stress factors leading to acute or adjustment insomnia may include the following:

• Jet lag
• Physical discomfort (hot, cold, lighting, noise, unfamiliar surroundings)
• Working different shifts
• Stressful life situations (divorce or separation, death of a loved one, losing a job, preparing for an examination)
• Illicit drug use
• Cigarette smoking
• Caffeine intake before going to bed
• Alcohol intoxication or withdrawal
• Certain medications

Most of these factors may be short-term, transient, and controllable or modifiable by actions a patient decides to take, and therefore insomnia may resolve in many patients when the underlying factor is removed or corrected.

There are no specific risk factors for insomnia because of the variety of underlying causes that may lead to insomnia. The medical and psychiatric conditions listed earlier may be considered risk factors for insomnia if untreated or difficult to treat. Some of the emotional and environmental situations that were also mentioned above may act as a risk factor for insomnia.

Impairment of daytime functioning is the defining and most common symptom of insomnia.

Other common insomnia symptoms include the following:

• Daytime fatigue
• Daytime sleepiness
• Mood changes
• Poor attention and concentration
• Lack of energy
• Anxiety
• Poor social function
• Headaches
• Increased errors and mistakes

In general, acute insomnia related to transient situational factors resolves spontaneously when the provoking factor is removed or corrected. However, a medical evaluation by a doctor may be necessary if insomnia persists or it is thought to be related to a medical or psychiatric condition. Many people choose not to discuss their insomnia symptoms with their doctor; however, individuals should contact their doctor if insomnia is interfering with daytime activities.

Some specialized doctors evaluate and treat insomnia and other sleep disorders. Sleep apnea may be evaluated by board-certified sleep physicians from varying backgrounds who have specialized in sleep disorders. Other doctors who evaluate and treat sleep disorders are neurologists with a specialty in sleep disorders.

Evaluation and diagnosis of insomnia may start with a thorough medical and psychiatric patient history taken by the doctor or other healthcare professional. As mentioned previously, many medical and psychiatric conditions can be responsible for insomnia.

A doctor will examine the patient to assess for any abnormal findings as well. Portions of the exam may include the following:

• Assessment of mental status and neurological function
• Heart, lung, and abdominal exam
• Ear, nose, and throat exam
• Measurement of the neck circumference and waist size.
• Questions about any routine medications you are currently taking, and the use of any illegal drugs, alcohol, tobacco, or caffeine.

Laboratory or blood work pertinent to these conditions can also be a part of the assessment. Doctors may also examine the following:

• Sleep patterns: The patient's family members and bed partners also need to be interviewed to ask about the patient's sleep patterns, snoring, or movements during sleep.
• Sleep habits: Specific questions regarding sleep habits and patterns are also a vital part of the assessment.
  • Asleep history focuses on:
    • Duration of sleep
    • Time of sleep
    • Time to fall asleep
    • Number and duration of awakenings
    • Time of final awakening in the morning
    • Time and length of any daytime naps
    • The typical sleep environment
• Sleep logs or diaries: Sleep logs or diaries may be used for this purpose to record these parameters daily for a more accurate assessment of your sleep patterns.
• Sleep history: Sleep history also typically includes questions about possible symptoms associated with insomnia. You may be asked about daytime functioning, fatigue, concentration and attention problems, naps, and other common symptoms of the condition.

Diagnostic tests

Other diagnostic tests may be done as part of the evaluation for insomnia, although they may not be necessary for all patients with insomnia.

• Polysomnography is a test that is done in sleep centers if medical conditions such as sleep apnea are suspected. In this test, the person will be required to spend a full night at the sleep center while being monitored for heart rate, brain waves, respiration, movements, oxygen levels, and other parameters while they are sleeping. The data is then analyzed by a specially trained physician to diagnose or rule out sleep apnea or other disorders of sleep.
• Actigraphy is another more objective test that may be performed in certain situations but is not routinely a part of the evaluation for insomnia. An actigraph is a motion detector that senses the person's movements during sleep and wakefulness. It is worn like a wristwatch for days to weeks, and the movement data are recorded and analyzed to determine sleep patterns and movements. This test may be useful in cases of primary insomnia disorder, circadian rhythm disorder, or sleep state misconception. Many commercially available devices are popular today for patients to use on their own and track their sleep patterns. The majority of these devices have not been evaluated against the gold standard devices and methods. Their role in identifying true insomnia has yet to be established in the scientific literature.

The treatment of insomnia depends largely on the cause of the problem. In cases where an obvious situational factor is responsible for insomnia, correcting or removing the cause generally cures the problem. For example, if insomnia is related to a transient stressful situation, such as jet lag or an upcoming examination, it will then be cured when the situation resolves.

Generally speaking, the treatment of insomnia can be divided into non-medical or behavioral approaches and medical therapy. Both approaches are necessary to successfully treat the problem, and combinations of these approaches may be more effective than either approach alone.

When it's related to a known medical or psychiatric condition, then appropriate treatment of that problem is at the forefront of therapy for insomnia in addition to the specific therapy for insomnia itself. Without adequately addressing the underlying cause, insomnia will likely go on despite taking aggressive measures to treat it with both medical and non-medical therapies.

The main classes of medications used to treat insomnia are sedatives and hypnotics, such as benzodiazepines and non-benzodiazepine sedatives.

Several medications in the benzodiazepine class have been used successfully for the treatment of insomnia, and the most common ones include:

• Quazepam (Doral)
• Triazolam (Halcion)
• Estazolam (ProSom)
• Temazepam (Restoril)
• Flurazepam (Dalmane)
• Lorazepam (Ativan)

Another common benzodiazepine, diazepam (Valium), is typically not used to treat insomnia due to its longer sedative effects.

Non-benzodiazepine sedatives are also used commonly for the treatment of insomnia and include most of the newer drugs. Some of the most common ones include:

• Zaleplon (Sonata)
• Zolpidem (Ambien or Ambien CR
• Zolpimist (Intermezzo)
• Eszopiclone (Lunesta)

Some anti-depressants (for example, trazodone [Desyrel], amitriptyline [Elavil, Endep], doxepin [Sinequan, Adapin]) can be used effectively to treat insomnia in patients who also may suffer from depression. Some anti-psychotics have been used to treat insomnia, although their routine use for this purpose is generally not recommended.

A doctor or sleep specialist is the best person to discuss these different medications and to decide which one may be the best for each specific individual. Many of these drugs have the potential for abuse and addiction and need to be used with caution. Several of these medications cannot be taken without the supervision of the prescribing doctor.

• Melatonin: a chemical released from the brain that induces sleep, has been tried in supplement form for the treatment of insomnia as well. It has been generally ineffective in treating common types of insomnia, except in specific situations in patients with known low levels of melatonin. Melatonin may be purchased over the counter (OTC without a prescription).
• Ramelteon (Rozerem): a newer drug that acts by mimicking the action of melatonin. It has been used effectively in certain groups of patients with the problem.
• Suvorexant (Belsomra): is a drug that belongs to a fairly new classification of medications for treating insomnia. It acts by decreasing the activity on orexin receptors in the wake system (lateral hypothalamus) of our brain, rather than increasing the activity in the sleep centers of our brain. The medication is an orexin antagonist. It is thought to be generally safe and well tolerated, but some patients may have side effects.
• Antihistamines: Other medications are not in the sedative or hypnotic classes, which have been used in the treatment of insomnia. Sedative antihistamines, diphenhydramine (Benadryl) have been used as sleep aids because of their sedative effects. However, this is not recommended due to many side effects and long-term drowsiness the following day.

There are several recommended techniques used in treating people with insomnia. These are non-medical strategies and are generally advised to be practiced at home in combination with other remedies for insomnia, such as medical treatments for insomnia and treatment for any underlying medical or psychiatric disorders.

Some of the most important of these behavioral techniques include:

• Sleep hygiene
• Stimulus control
• Relaxation techniques
• Sleep restriction

Behavioral sleep specialists may also be available in some clinics and can be very helpful in managing non-medical treatment options. They may use additional techniques dealing with cognitive behavioral therapy, including some biofeedback methods that help patients with insomnia relax and transition to sleep. They also may recommend you keep a sleep diary.

Sleep Hygiene

Sleep hygiene is one of the components of non-medical treatments for insomnia, and includes simple steps that may improve the initiation and maintenance of sleep.

Sleep hygiene consists of the following strategies:

• Sleep as much as possible to feel rested, then get out of bed (do not oversleep).
• Maintain a regular sleep schedule. Go to bed and wake up at the same time daily.
• Do not force yourself to sleep.
• Do not drink caffeinated beverages or other stimulants in the afternoon or evening.
• Do not drink alcohol before going to bed.
• Do not smoke, especially in the evening.
• Adjust your bedroom environment to induce sleep.
• Avoid watching television in bed and for 30 minutes before bed.
• Do not go to bed hungry, but avoid foods that may cause reflux.
• Reduce stress and anxiety before going to bed.
• Exercise regularly, but not 4-5 hours before bedtime.

Stimulus Control

Stimulus control refers to techniques used to help with initiating sleep. These techniques are used to induce an environment in the bedroom that promotes sleep.

Some simple steps include:

• Use the bed only for having sex and sleeping, not working, reading, watching TV, eating, or other mentally stimulating activities.
• Go to bed only when you feel ready to sleep.
• Turn off the lights and all the noise in and around the bedroom.
• Get up at the same time every morning to avoid oversleeping.
• If you do not fall asleep longer than 20 minutes after going to bed, get up and try some relaxation techniques until you are ready to sleep again.

Relaxation techniques, which are also a part of non-medical therapy for insomnia, involve sitting or lying comfortably and relaxing muscles of the body in one area at a time. This may be combined with deep, relaxed breathing to promote further body relaxation.

Sleep Hygiene

Sleep hygiene is one of the components of non-medical treatments for insomnia, and includes simple steps that may improve the initiation and maintenance of sleep.

Sleep hygiene consists of the following strategies:

• Sleep as much as possible to feel rested, then get out of bed (do not oversleep).
• Maintain a regular sleep schedule. Go to bed and wake up at the same time daily.
• Do not force yourself to sleep.
• Do not drink caffeinated beverages or other stimulants in the afternoon or evening.
• Do not drink alcohol before going to bed.
• Do not smoke, especially in the evening.
• Adjust your bedroom environment to induce sleep.
• Avoid watching television in bed and for 30 minutes before bed.
• Do not go to bed hungry, but avoid foods that may cause reflux.
• Reduce stress and anxiety before going to bed.
• Exercise regularly, but not 4-5 hours before bedtime.

Insomnia overall has a favorable outlook. Many cases of insomnia are related to transient situational stresses and are easily reversed when the situation is resolved. In cases of long-standing (chronic) insomnia, any medical or psychiatric cause needs to be assessed and treated.

Medical and non-medical home remedies are available for treating insomnia and are generally successful. Combinations of non-medical and medical therapy are usually the most successful. Medical treatment for insomnia without addressing the underlying cause of a person's insomnia will often result in long-term medication use with no resolution of the underlying cause.

Various factors increase the risk of getting cancer. An improper sleeping schedule or a lack of required sleep may be a risk factor for certain cancers and may interfere with the effectiveness of treatment. However, cancer causes sleep disturbances, which may affect treatment outcomes.

Cancer treatments have side effects, such as anxiety, depression, deep fatigue, digestive problems, hot flashes, night sweats, and pain, which can result in insomnia.

Studies show that sleep duration, sleep quality, and circadian rhythms affect cancer risk.

• Sleep duration: Research reports that people who sleep less than six hours have an increased chance of death of any cause, but the major factor is the increased risk of cancer.
• Sleep quality: It is difficult to measure the quality of sleep. The following results reported by some observational studies:
  • A study done on 4000 women found a link between restless sleep and triple-negative breast cancer, a severe form of the disease.
  • A small study on men with sleep disturbances had an increased risk of developing prostate cancer.
• Circadian rhythm:
  • Circadian rhythm is the body's biological clock, which runs 24 hours a day.
  • Few types of research have reported evidence that circadian rhythm disturbances play a significant role in cancer development.
  • Circadian rhythms are involved in cell growth, gene mutations, and DNA damage. The circadian rhythm influences immunity and hormone production.
  • Disturbances in the circadian rhythm may increase the risk of causing breast cancer and cancers of the liver, colon, lung, pancreas, and ovaries.
  • A few researchers have suggested that exposure to carcinogens and circadian rhythm disturbances may elevate cancer risk.

Healthy sleeping habits may improve sleep patterns.

The following are a few ways to prevent insomnia:

• Keep sleeping times and wake-up times consistent even on weekends
• Limit nap times
• Stay active during the day, which improves nighttime sleep
• Limit caffeine, alcohol, and heavy meals during nighttime
• Make your bedding comfortable
• Make a daily ritual of taking a warm bath, listening to music, or reading before bed